Trinity Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trinity, Texas.
- Location
- 314 E Caroline St, Trinity, Texas 75862
- CMS Provider Number
- 676439
- Inspections on file
- 40
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 38 (3 serious)
Citation history
Health deficiencies cited at Trinity Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure effective communication training was completed for 6 of 17 direct care staff, including CNAs, LVNs, and the ADON. Record review showed each had a hire date documented, but no evidence of initial effective communication training in their personnel files. During interviews, the ADON, HR, Administrator, and DON stated they were responsible for ensuring required orientation training was completed before staff began resident care and annually, and the facility policy listed effective communication with residents and family as a required topic.
Missing Infection Control Training for Multiple Staff: The facility failed to provide required infection prevention and control training for 9 of 17 direct care staff reviewed, including CNAs, LVNs, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire training for several employees and no annual training for one CNA. Interviews with the ADON, HR, Administrator, and DON confirmed the training was not completed as required, despite a facility policy requiring initial orientation and in-service training on infection prevention and control standards, policies, and procedures.
Missing Required Behavioral Health and Communication Training: The facility failed to ensure required behavioral health and effective communication training was completed for 9 of 17 staff reviewed, including CNAs, LVNs, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire training for most of the staff and no annual training for one CNA. Interviews with the ADON, HR, Administrator, and DON confirmed the training was not completed as required, despite the facility policy listing behavioral health fundamentals and related topics as mandatory.
A resident with intact cognition received Olanzapine for major depressive disorder with psychotic symptoms, but the medication consent form in the chart was not signed by the resident or RP. The care plan addressed psychotropic medication education, the MAR showed daily administration, and staff interviews confirmed the facility expected signed consent to be in place before starting psychotropic meds.
A resident with dementia, depression, anxiety, and bipolar disorder was not referred for a new PASRR review after receiving a new bipolar dx. Records showed a prior PL1 was negative, while the MDS, care plan, and physician orders documented the psychiatric dx and use of a mood stabilizer. Interviews confirmed the prior MDS coordinator should have completed the required form 1012 and submitted a new PL1/PE if needed.
Failure to Provide Baseline Care Plan Summary: A resident admitted with a hip fx, osteoporosis, and COPD did not receive an initial baseline care plan meeting or a summary for the resident/RP within the required timeframe. The resident had moderate cognitive impairment and was dependent on staff for personal hygiene. Staff interviews and record review showed no care plan meeting was scheduled, and the SW and Regional MDS acknowledged the initial meeting and summary were not completed as expected.
Care Plan Conference Not Held and Representative Not Invited: A resident with AFib, MDD, GERD, an indwelling catheter, and an ostomy did not have a quarterly care plan conference held as expected, and the resident representative/family was not present. The resident said she was unsure about care plan meetings and had not been asked to attend, while staff interviews showed the missed meeting was not recognized at the time.
A resident with atrial fibrillation, MDD, and GERD was given morning meds by an LVN, but the nurse did not stay to verify ingestion and the pills were later found in a cup at the bedside. The resident said she had not taken them yet, and the LVN stated she became distracted and did not ensure the meds were swallowed. The DON, ADON, and Administrator stated staff should watch residents take and swallow meds, and the resident was not identified as able to self-administer.
A resident reported cold meals when eating in her room, and surveyors observed test trays delivered after the dining room meal service had ended. The puree tray was cold at 88 degrees, and the DM described the green beans as awful and the food as cold; the Administrator and DON acknowledged that residents served cold food might not eat it and could lose weight. The facility policy addressed maintaining proper hot and cold temperatures during food service but did not address tray temperatures for residents served in their rooms.
An LVN worked with an expired license after the facility failed to properly verify her credential status. The DON was unaware of the expired license, and the Administrator said the issue was found during an audit of licensed nurses. HR stated license checks were done on hire and annually, but the report used did not fully show the expiration date. The LVN said she did not know her license had expired.
A resident with an indwelling catheter and ostomy received incontinent and foley care from two CNAs who did not follow proper hand hygiene and glove practices. One CNA touched a clean brief with dirty gloves and changed gloves without sanitizing, while the other removed only one glove, used barrier cream, and then sanitized and re-gloved one hand only. The ADON, DON, and Administrator stated staff should remove both gloves and perform hand hygiene between dirty and clean tasks, and the facility policy required hand hygiene after removing gloves and before and after handling invasive devices.
Staff training requirements were not fully completed for 2 employees reviewed, including an Activity Director and a Dietary Manager. Record review showed missing on-hire training in areas such as effective communication, HIV, dementia, infection control, restraint reduction, falls, and behavioral health. HR said she was new to the role and was not aware the required new hire training had not been completed, while the Administrator and DON stated they were responsible for ensuring required orientation and annual training were completed.
Failure to Complete Required Resident Rights Training: The facility failed to ensure CNA E completed required education on resident rights and facility responsibilities. Record review showed CNA E had no evidence of annual training since hire, and training was only initiated after surveyor entrance but not completed. The HR Coordinator, Administrator, and DON each stated the training was required on hire and annually, and facility policy listed resident rights and responsibilities as a required topic.
Missing Required Abuse and Dementia Training for CNA: The facility failed to ensure a CNA completed required annual training on abuse, neglect, exploitation, and dementia management. Record review showed the CNA’s training was not completed, and HR and the Administrator confirmed there was no evidence of the required annual in-service training in the file. The facility policy required staff training on abuse prevention, reporting procedures, and dementia management.
CNA Annual In-Service Training Not Completed: The facility failed to ensure CNA E completed the required annual in-service education. Record review showed no documentation of the required 12 hours of annual training, including topics such as resident rights, abuse, dementia, infection control, effective communication, falls, restraints, and behavioral health. Electronic records showed training was started but not completed, and the ADON, HR, Administrator, and DON all acknowledged responsibility for ensuring CNA training was completed.
A resident with diabetes, hemiplegia, a colostomy, and an indwelling Foley catheter, who was care planned as dependent for toileting and at risk for skin breakdown, was found in bed with a strong urine odor, a urine-soaked pillowcase between the thighs, wet groin and inner thighs with redness, a saturated underpad with brown rings up to the upper back, and white, flaky skin around the penis, along with a small open area on a previously healed sacral wound and long, dirty fingernails. Two CNAs reported that residents were supposed to be checked every 2 hours, but one had only emptied the catheter bag earlier in the shift without providing incontinence care, and both indicated the resident appeared not to have been changed overnight. The resident stated staff had come in a couple of times overnight when the catheter began leaking, that this was the first visit that morning, that he could tell when he was wet, and that he disliked having dirty nails. The DON and Administrator confirmed expectations for 2-hour checks, walking rounds at shift change, and cleaning nails when visibly soiled, and acknowledged that being left wet was unacceptable and could result in skin breakdown, infections, or mental anguish.
A resident with incontinence, diabetes, and impaired mobility did not receive timely and appropriate skin assessment and care as outlined in the care plan and facility protocols. The resident reported long waits for incontinence care and ongoing genital discomfort. On observation, CNAs provided proper perineal care technique during the survey visit, but the resident’s scrotum was reddened and open wounds were present on the inner thigh. Nursing staff, including the charge nurse and treatment nurse, were unaware of any active skin issues because a CNA had noticed genital redness for about a week but failed to report it, instead applying barrier cream independently. Subsequent assessment identified new in-house moisture-associated skin damage/incontinence-associated dermatitis with documented wound measurements, despite existing policies and in-services requiring immediate reporting of redness and other skin changes.
A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and total dependence for ADLs was transferred with a mechanical lift by two CNAs who failed to lock the lift’s wheels as required by the care plan and facility policy. One CNA operated the lift without engaging the wheel lock, causing a wheel to lift off the floor during lowering, and then stood on the lift to force the wheel down while the other CNA guided the resident into a wheelchair. The CNA operating the lift reported she believed the lock was broken, stated she had previously informed the DON and had refused to use the lift in the past, and said this lift was used because other battery-operated lifts were not fully charged. The DON and Administrator stated that two staff are required for lift use, wheels should be locked when in position, staff should not use malfunctioning equipment, and issues should be reported, consistent with the facility’s safe lifting policy.
A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and total dependence for ADLs was care planned to require a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs used a mechanical lift but one CNA failed to lock the wheels before lifting and moving the resident, resulting in a wheel lifting off the floor and the CNA standing on the lift to force the wheel down while the other CNA guided the resident into a wheelchair. One CNA stated she believed the wheel lock was broken, that this was the only usable lift because others were not charged, and that she had reported the issue and previously refused to use the lift. The DON reported that mechanical lift use required two staff, locked wheels, and competency check-offs on hire and annually, but documentation showed one CNA lacked a mechanical lift competency on hire and no such record was found for the other CNA, despite facility policy requiring competency evaluations.
A resident with severe cognitive impairment and a stage 4 pressure ulcer had active orders and a care plan requiring Enhanced Barrier Precautions (EBP), including gown and gloves, during high-contact care such as dressing. Despite an EBP sign posted on the door, a CNA provided incontinent care, dressed, and repositioned the resident while wearing only gloves and no gown, then left the room after discarding the gloves and sanitizing hands. In interviews, the CNA reported not realizing the resident was on EBP and noted the absence of PPE in the hallway, while the DON and Administrator confirmed that residents with chronic wounds require gown and glove use for high-contact care under facility policy and existing EBP orders.
A resident with metabolic encephalopathy, dementia, psychiatric illness, muscle weakness, and a history of falls experienced numerous witnessed and unwitnessed falls over several months, including falls with injury and visible bruising in various stages of healing. The resident, who required assistance with transfers and was identified as high risk for falls, was described by staff as impulsive, often refusing to use the call light and "throwing" himself between bed and wheelchair, especially to go smoke. Although some fall-prevention measures such as a low bed, fall mats, call light access, room rearrangement, frequent checks, therapy, pharmacy review, and occasional 1:1 supervision were in place, the DON acknowledged that no new interventions were implemented as falls recurred. Staff also reported limited facility-based behavioral training despite the resident’s challenging behaviors and worsening agitation after family-installed cameras were used to prompt him to get up, leading to the cited deficiency for failure to provide adequate supervision and to develop and implement effective fall-prevention interventions.
A resident with moderate cognitive impairment, multiple medical conditions, and significant behavioral issues (yelling, striking staff, throwing objects) sustained a skin tear on the forearm after a CNA, who reported being hit multiple times during ADL care, grabbed the resident’s arm/hand to block further blows. Nursing notes documented the behavior episode and resulting skin tear, and the family reported being told that the CNA grabbed the resident’s arm and also claimed to have video of the CNA grabbing the resident while assisting him back to bed. The Admin, who was out of the country at the time, acknowledged she did not report the allegation to the state, did not investigate it, and did not suspend the CNA, despite the facility policy requiring immediate (within 2 hours) reporting and thorough investigation of alleged abuse or injuries of unknown source. CNA and LVN staff stated they had not received facility-based behavioral training, even though they regularly cared for this behaviorally challenging resident.
A resident with moderate cognitive impairment, multiple comorbidities, and a history of falls required extensive assistance with ADLs and was known to exhibit agitation and striking behaviors. During ADL care, the resident screamed, struck a CNA multiple times, and attempted to hit her in the face; the CNA grabbed the resident’s arm/hand to block further hits, and the resident sustained a skin tear on the forearm that was later assessed and treated by nursing staff. The CNA and an LVN who witnessed the event reported the incident to the DON and the administrator, and the family was informed that the CNA had grabbed the resident’s arm and caused a laceration. The administrator, who was out of the country, acknowledged she did not personally report or investigate the allegation and assumed the DON had notified the state, resulting in the facility’s failure to report an alleged abuse incident to the administrator and State Survey Agency within the required 2-hour timeframe, contrary to its abuse investigation and reporting policy.
A resident with metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, and moderate cognitive impairment experienced repeated falls and behavioral escalation over an extended period. Although the care plan identified high fall risk and psychotropic use, it contained only general fall precautions and basic behavior monitoring, without individualized interventions for impulsivity, aggression during care, or de-escalation strategies. Staff interviews confirmed the resident frequently became agitated, attempted to strike staff, and threw himself during transfers, and that they had no structured guidance in the care plan. The MAR included a PRN order for Naloxone (Narcan) and shift monitoring for opioid overdose, but the care plan did not address suspected overdose or emergency response actions. The DON acknowledged that no new interventions were added to the care plan despite ongoing falls and behavioral concerns.
A resident with multiple comorbidities, moderate cognitive impairment, and a history of substance abuse had a standing PRN order for intranasal naloxone (Narcan) for suspected opioid overdose and an order for shift-by-shift monitoring for overdose indicators, which staff consistently documented as absent. On one occasion, the resident was found unresponsive but breathing, and staff, who suspected possible drug use and opioid toxicity, called EMS but did not administer Narcan prior to EMS arrival, despite facility policy directing naloxone use when overdose is suspected and Narcan being available on-site. EMS administered two doses of intranasal naloxone, after which the resident became alert, while a CNA and an LVN later confirmed prior suspicions of family-provided drugs and uncertainty among staff about giving Narcan.
A resident with a PICC line for IV access did not have this device or its required care interventions included in their care plan, despite physician orders for dressing changes and ongoing IV therapy. Staff interviews confirmed the omission, and facility policy requires care plans to be updated to reflect all current needs.
A resident with a PICC line did not have their dressing changed within the required 7-day interval as ordered by the physician and facility policy. Staff interviews confirmed that only RNs could perform the dressing change, but the overdue change was not identified until the survey. The lapse was acknowledged by clinical leadership, who recognized the importance of timely dressing changes to prevent infection.
A resident with multiple chronic conditions and dependent on staff for ADLs did not receive scheduled showers or adequate hair care, resulting in a large hair mat that required cutting. Documentation of hygiene care was incomplete or missing, and staff did not consistently document or communicate refusals or care provided, contrary to facility policy.
A resident with multiple chronic conditions who required assistance with ADLs did not have complete or accurate documentation in their clinical records for baths, showers, hair care, or refusals of care. Staff interviews and record reviews confirmed that scheduled care and refusals were often not documented, and required notifications were not consistently made, contrary to facility policy.
The facility failed to promptly notify physicians and obtain wound care orders when residents experienced changes in condition, such as the development or worsening of pressure injuries. For example, a resident with a new unstageable pressure injury did not have the wound care physician notified for two days, and another resident admitted with severe pressure injuries did not have wound care orders implemented until several days after admission. Staff interviews revealed ongoing issues with accountability, documentation, and timely communication regarding wound care and physician notification.
Multiple residents with or at risk for pressure injuries did not receive timely or consistent wound care, weekly skin assessments, or implementation of dietary and support surface interventions as ordered. Nursing staff failed to document or perform required treatments, and there was a lack of accountability and communication regarding wound care orders and changes in condition, resulting in the development and worsening of pressure ulcers.
Two residents experienced significant medication errors when critical medications for hypertension, heart failure, and anticoagulation were either not administered or not ordered as required. One resident did not receive Metoprolol and Entresto as prescribed, while another did not have Entresto ordered upon admission and missed multiple doses of Eliquis, with documentation gaps in the MAR. Staff interviews revealed inconsistent practices in medication reconciliation, order entry, and documentation of refusals, contributing to these errors.
The facility failed to ensure that a resident who fell and hit her head received prompt assessment, neuro checks, and timely notification of the physician and family by the assigned RN, with required documentation and incident reporting not completed. Additionally, nurses did not perform or document head-to-toe skin assessments after a CNA identified possible ant bites on three residents, and weekly skin assessments were not documented as required.
A resident with multiple chronic conditions did not receive several ordered medications on multiple occasions, as shown by unexplained blanks in the MAR. Staff interviews indicated a lack of documentation and accountability for missed doses, and the resident reported increased pain when medications were not administered. Facility policy requires documentation for any missed or withheld medications, but this was not followed.
Staff failed to follow infection control protocols during care of three residents, including not performing hand hygiene before donning gloves, not changing gloves between dirty and clean tasks, and not wearing required PPE such as gowns during wound care under enhanced barrier precautions. These lapses occurred despite staff having received relevant training and facility policies outlining proper procedures.
A resident with multiple chronic conditions did not have a comprehensive care plan meeting held or rescheduled after a hospitalization, resulting in the resident and her representative not being invited or included in the required quarterly care plan review. Facility staff confirmed the oversight, and records showed no care plan conferences occurred after the missed meeting, contrary to facility policy requiring regular interdisciplinary care plan development with resident and representative participation.
The facility's kitchen failed to maintain sanitary conditions, with the dish machine not reaching the required temperature and expired, moldy food items found in the refrigerator. Staff were unaware of these issues, and the kitchen was short-staffed, complicating daily checks. The Administrator was not informed of the problems, and facility policies on dishwashing and food storage were not followed.
The facility failed to maintain an effective pest control program, resulting in a roach infestation in the kitchen. Observations revealed roaches on walls, floors, and near food preparation areas. Despite monthly pest control treatments, the issue persisted, with staff acknowledging the ongoing problem. The Administrator expressed concerns about foodborne illness risks due to the infestation.
The facility failed to complete baseline care plans within 48 hours for three residents, including a resident with cellulitis, another with a hip fracture, and a third with sepsis due to MRSA. This deficiency was identified through record reviews and staff interviews, revealing that the DON was responsible for ensuring these plans were completed, with the weekend RN handling weekend admissions. The facility's policy requires baseline care plans to be developed within 48 hours to meet residents' immediate care needs.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene and PPE protocols. A CNA did not sanitize hands between handling meal trays, and staff did not wear required PPE for residents on enhanced barrier precautions or contact isolation. These lapses in infection control practices could lead to cross-contamination and increased infection risk.
The facility failed to provide required effective communication training to six new staff members, including LVNs, a SW, and CNAs, during their orientation. This oversight was identified through employee file reviews and acknowledged by the Administrator, who was unaware of the training requirements. The DON recognized the potential risks of inadequate training, such as staff being unable to deescalate situations or communicate effectively with residents, especially those with dementia.
The facility failed to provide mandatory infection control training to five staff members upon hire, as required by their infection prevention and control program. This oversight was identified through interviews and record reviews, with the Administrator acknowledging the lapse and the DON assuming responsibility for future training.
The facility failed to ensure CNAs completed mandatory training in Abuse, Neglect, and Exploitation (ANE) and dementia management during orientation. Three CNAs were identified as not having completed these trainings, and interviews revealed a lack of awareness and responsibility for training requirements. The Administrator and DON acknowledged the potential risk to residents from untrained staff.
The facility failed to provide mandatory behavioral health training for six employees, including LVNs, a SW, and CNAs, upon hire. Personnel files showed no evidence of completed training, and interviews revealed a lack of awareness and oversight by the Administrator and DON, potentially placing residents at risk.
A resident's Hydrocodone-Acetaminophen tablets were misappropriated due to the facility's failure to follow proper medication receipt and storage procedures. Staff interviews revealed that the required verification process involving two nurses and the pharmacy delivery person was not adhered to, leading to the medication's disappearance. The incident was reported to the police for investigation.
A resident's room in an LTC facility was found to have a privacy curtain with a suspected feces stain and a wheelchair with a strong urine odor. Staff interviews revealed inconsistencies in cleaning responsibilities and schedules, with the Maintenance Supervisor and housekeeping staff unaware of the issues until reported. The facility's policy on cleaning was not followed, leading to unsanitary conditions.
A facility failed to conduct a Level II PASARR review for a resident who returned from a behavioral hospital with a new diagnosis of major depressive disorder. The MDS Coordinator did not complete the necessary documentation, and the DON and Administrator were unaware of the PASARR process, leading to a lack of required evaluations and potential service provision.
The facility failed to provide necessary ADL assistance for two residents, leading to deficiencies in personal hygiene and grooming. A resident with COPD did not receive the required assistance with bathing, as her care plan indicated, and expressed not having a shower or bed bath in over a year. Another resident with a stroke was observed with long, dirty nails and reported not receiving proper nail care or a recent shower. Both residents expressed a desire to be clean, highlighting the facility's failure to follow care plans and ensure proper hygiene.
A resident with dementia and bipolar disorder was found with smoking materials in his possession, contrary to the facility's policy requiring supervision and secure storage of such items. The resident was observed with a lighter and cigarettes in his room and on his person, despite the facility's policy that smoking materials be locked away. The DON and Administrator confirmed the policy breach, acknowledging the risk of fire or injury.
The facility failed to document the required witness signatures for drug destruction in January and February 2025, with records lacking the necessary signatures from the DON, ADON, and Pharmacist. The DON was unaware that other staff could serve as witnesses, and the Administrator was not involved in the process, leading to a risk of drug diversion.
Missing Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide effective communication mandatory training for 6 of 17 direct care staff reviewed for training requirements, including CNA K, CNA F, LVN A, LVN L, LVN M, and the ADON. Record review showed that CNA K, CNA F, LVN A, LVN L, LVN M, and the ADON each had a documented hire date, but there was no evidence in their personnel files that initial hire training on effective communication had been completed. During interviews, the ADON stated he was not aware the effective communication training had not been completed before he started resident care and explained that training was assigned through a computer program by HR or corporate. HR stated she was new to the position and was not aware that effective communication training had not been completed as required for all employees, and said she would complete a checklist for required training going forward. The Administrator and DON both stated they were responsible for ensuring staff received required orientation training on effective communication prior to employment and annually. The facility policy revised 02/2026 stated that all personnel must participate in initial orientation and regularly scheduled in-service training, and that required training topics include effective communication with residents and family for direct care staff.
Missing Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to provide mandatory training on the infection prevention and control program standards, policies, and procedures for 9 of 17 direct care staff reviewed. Record review showed no evidence of initial hire infection prevention and control training for CNA K, CNA F, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, and the ADON, and no evidence of annual infection prevention and control training for CNA E. The personnel files reviewed showed hire dates for each of these employees, but the required infection control training documentation was absent. During interviews, the ADON stated he was not aware the infection control and prevention training had not been completed on his hire date before he started resident care and said staff were assigned training through a computer program. The HR staff member said she was new to the position and was not aware the required infection control training had not been completed for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos, and acknowledged responsibility for ensuring required orientation and annual training were completed. The DON also stated nursing staff were responsible for receiving infection control training during orientation prior to employment and annually. A facility policy revised 02/2026 required all personnel to participate in initial orientation and regularly scheduled in-service training, including infection prevention and control program standards, policies, and procedures.
Missing Required Behavioral Health and Communication Training
Penalty
Summary
The facility failed to provide mandatory behavioral health training and effective communication training for 9 of 17 direct care staff reviewed for training requirements, including CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire behavioral health training for CNA K, CNA F, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, or the ADON, and no evidence of annual behavioral health training for CNA E. The personnel files reviewed documented hire dates for each of these employees, but the required behavioral health training was not found in the records. During interviews, the ADON stated he was not aware the behavioral health training had not been completed before staff began resident care and said the training was assigned through a computer program by HR or corporate. HR stated she was new to the position and was not aware the behavioral health training had not been completed as required for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention, and the DON stated she was responsible for ensuring nursing staff received the required behavioral health training during orientation prior to employment and annually. The facility policy revised 02/2026 stated all personnel must participate in initial orientation and regularly scheduled in-service training, and listed Behavioral Health Fundamentals, Person-Centered Behavior Management, and Dementia Care as required training topics.
Unsigned consent for antipsychotic medication
Penalty
Summary
The facility failed to ensure that Resident #1 had informed consent in place for Olanzapine, an antipsychotic medication, when it was ordered. Resident #1 was a female admitted to the facility with a diagnosis of pneumonia and had a quarterly MDS showing a BIMS score of 13, indicating intact cognition. Her care plan identified use of Olanzapine and included an intervention to educate the resident, family, or caregivers about the risks, benefits, and side effects of psychotropic medications. The physician order summary showed Olanzapine 5 mg daily for major depressive disorder with psychotic symptoms, and the MARs showed she received the medication daily from October 2025 through April 2026. Review of the medication consent record showed an HHSC form 3713 was uploaded for Olanzapine, but it was not signed by the resident or responsible party. During interviews, the consultant pharmacist said she would expect any resident on Olanzapine to have a signed consent in place. The DON said she was unsure how the consent was scanned without a signature and stated the ADON was responsible for ensuring consents were signed. The Administrator and ADON both stated that nursing staff were responsible for ensuring psychotropic medication consents were signed and in place before treatment began, and the ADON said he was not aware Resident #1 lacked a signed consent.
Failure to Coordinate PASRR Review After New Bipolar Diagnosis
Penalty
Summary
The facility failed to coordinate with the appropriate state-designated authority for PASRR when Resident #45 received a new diagnosis of bipolar disorder. Record review showed the resident was admitted with diagnoses including dementia, bipolar disorder, depression, and anxiety disorder, and a quarterly MDS indicated severe impairment in thinking with a BIMS score of 3 and psychiatric/mood disorders of anxiety disorder, depression, and bipolar disorder during the look-back period. The resident’s care plan referenced use of a mood stabilizing medication related to bipolar disorder, and physician orders listed bipolar disorder with a start date of 3/6/2024. A PASRR Level 1 screening dated 2/26/2024 indicated the resident was negative for mental illness, intellectual disability, and developmental disability. During interviews, the Regional MDS Coordinator stated the previous MDS Coordinator was responsible for PASRR and that, after a new mental illness diagnosis, a form 1012 should be completed and a new PL1 and PE submitted if necessary; she said Resident #45 did not have a new PL1 after receiving the new diagnosis and should have. The Administrator stated the previous MDS Coordinator should have completed the form 1012 when the new diagnosis was given, and the facility policy stated a PASRR resident review will be requested when a resident experiences a significant change in condition suggesting mental illness that was not previously identified.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide Resident #58 and/or her responsible party with a summary of the baseline care plan within 48 hours of admission. Resident #58 was admitted with a displaced intertrochanteric fracture of the right femur, age-related osteoporosis, and COPD. Her admission MDS reflected moderate impairment in thinking with a BIMS score of 12, dependence on staff for personal hygiene, and participation by the resident and family in the assessment process. The facility care plan dated 2/26/2026 included an intervention to provide the resident and representative with a summary of the baseline care within 48 hours of admission. Record review of the care plan meeting schedule for January 2026 through April 2026 showed Resident #58 was not scheduled for a care plan meeting. During observation and interview, the resident stated she had not had a care plan meeting since admission. Staff interviews indicated the previous MDS Coordinator had been responsible for coordinating care plan meetings, then the responsibility was reassigned to the SW. The SW stated Resident #58 did not have an initial care plan meeting within 48 hours and did not know why. The Regional MDS stated new admissions should have an initial meeting within 48 hours after admission and the resident/family should receive a copy of the summary. The Administrator stated the baseline care plan should be done within 72 hours of admission and that residents/families could be at risk of not being informed of what was going on with them if meetings were not conducted.
Care Plan Conference Not Held and Representative Not Invited
Penalty
Summary
The facility failed to ensure a comprehensive care plan was prepared by an interdisciplinary team with participation from the resident and the resident representative for Resident #16. Resident #16 was admitted with diagnoses including atrial fibrillation, major depressive disorder, and GERD. A quarterly MDS assessment dated 2/27/2026 showed she had a BIMS score of 15, required substantial/maximal assistance with personal hygiene, and had an indwelling catheter and an ostomy. Her care plan dated 9/9/2025 addressed the indwelling catheter with interventions for catheter care at least once per shift and after each bowel movement. Record review showed the last care plan conference for Resident #16 was held on 12/10/2025, and the resident was not in attendance; the resident was invited and opted not to attend, but the resident representative/family was not in attendance. During interview, Resident #16 said she was not sure about any care plan meetings and had not been asked to attend one since she had been at the facility. Staff interviews indicated the resident should have had a quarterly meeting in March 2026, but the meeting was not held, and staff were not aware it had been missed. The facility policy stated the interdisciplinary team, in conjunction with the resident and family or legal representative, develops and implements a comprehensive, person-centered care plan and that the care planning process facilitates resident and/or representative involvement.
Medication Left at Bedside Without Verification of Ingestion
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of medications for Resident #16. Resident #16 was admitted with diagnoses including atrial fibrillation, major depressive disorder, and GERD, and her quarterly MDS indicated a BIMS score of 15 with no impairment in thinking. Her care plan did not indicate that she was able to self-administer medications. On 4/14/2026, the MAR showed LVN A documented administration of morning medications, including ascorbic acid, loratadine, magnesium oxide, multivitamin, saccharomyces, and peppermint oil. During an observation at 9:51 a.m. on 4/14/2026, Resident #16 was awake in bed and there was a cup of pills on her over-bed table. She stated the nurse had given them to her earlier and she had not taken them yet. LVN A later stated she had given the resident her morning medications but became distracted and did not make sure the resident took them, and that medications should never be left at the bedside. The DON, ADON, and Administrator all stated staff should stay with residents and watch them take and swallow medications, and the DON said she had given LVN A a 1:1 verbal in-service on 4/14/2026. The facility policy stated residents may self-administer medications only if the attending physician and interdisciplinary care planning team determine they can do so safely after a Medication Self-Administration Evaluation.
Cold and Unappetizing Pureed Meals Served
Penalty
Summary
Food served to residents was not palatable and was served at an unsafe temperature during the noon meal observation. During the initial tour, a resident reported eating meals in her room and complained of cold food. On 4/14/26, test trays left the kitchen after the dining room had already been served and were later delivered to the conference room. The trays included one regular tray with chopped chicken, rice, peas/carrots, and a roll, and one puree tray with chicken, carrots, green beans, and a roll. When the covers were removed, the puree food was cold, and the surveyor’s temperature gun showed 88 degrees. The regular food was warm and tasted okay, but the puree food was cold to taste and the green beans were bland. During the same observation, the Dietary Manager checked the temperature of the pureed food and also found it to be 88 degrees. She tasted the green beans, made a face, and stated they were awful and that the food was cold. She said residents served cold food might not eat it and could lose weight. The Administrator and DON both stated they would not want to be served cold food and acknowledged that residents might not eat it and could be at risk for weight loss. The facility policy titled Food Preparation and Service stated that proper hot and cold temperatures are maintained during food service, but it did not address serving temperature of food on trays when served to residents in their rooms.
Expired LVN License Not Identified
Penalty
Summary
The facility failed to ensure that one of six licensed staff reviewed, LVN B, maintained an active nurse license in accordance with state law. Record review showed LVN B was hired at the facility and that a Texas Board of Nursing verification checked by the facility showed her license had expired. A daily staffing assignment/sign-in log also showed LVN B worked on a day after the license expiration was identified in the record review. During interviews, the DON said she was not aware LVN B had an expired nurse license. The Administrator said she learned of the expired license during an audit of licensed nurses and stated LVN B was immediately removed from the schedule. HR said license checks were done on hire and annually, but the last check of licensed staff was completed in [DATE] and LVN B's expiration was missed because the report was not fully reviewed to see the expiration date. LVN B said she did not know her license had expired and stated she had last renewed it in [DATE]. The facility policy on credentialing nursing service personnel required staff who provide resident care or treatment within the scope of their license or certification to present verification of such license.
Hand Hygiene and Glove Use Not Followed During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. During incontinent and foley care for a resident with diagnoses including atrial fibrillation, major depressive disorder, and GERD, CNA C and CNA D did not consistently perform hand hygiene or glove changes during care. The resident had a BIMS score of 15, required substantial to maximal assistance with personal hygiene, and had an indwelling catheter and an ostomy. During observation in the resident’s room, both CNAs entered with supplies, sanitized their hands, and donned gloves and gowns. CNA C cleaned the resident’s inner thighs, vagina, and foley tubing, then touched a clean brief with dirty gloves before removing the gloves and putting on clean gloves without washing or sanitizing hands. CNA D emptied the urine drainage bag, removed one glove while in the bathroom and washed her hands, then later assisted with turning the resident, cleaned the buttocks and perineal area, applied barrier cream with one gloved hand, removed only that glove, and used hand sanitizer before placing a glove back on that same hand. Both staff later removed their gowns and gloves and exited the room. In interviews, CNA D stated she had been taught to keep one hand for dirty tasks and one for clean tasks, and said she removed only the glove from the hand used for barrier cream. CNA C stated she should have changed gloves when moving from cleaning the front to the back and acknowledged touching a clean brief with dirty gloves and not sanitizing between glove changes. The ADON, DON, and Administrator stated staff should not have one clean hand and one dirty hand, should remove both gloves and perform hand hygiene between glove changes, and should not touch clean items with dirty gloves. The facility policy on hand hygiene stated hand hygiene is the primary means to prevent the spread of infections and requires hand hygiene before and after handling invasive devices and after removing gloves.
Staff Training Program Not Completed for New Hires
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for 2 of 17 employees reviewed for training requirements: the Activity Director and the Dietary Manager. Record review showed the Activity Director was hired on 04/01/2026 and did not have evidence of on-hire training in effective communication, HIV, dementia, infection control, or restraint reduction. Record review also showed the Dietary Manager was hired on 03/10/2026 and did not have evidence of required training on falls, dementia, infection control, or behavioral health on hire. During interviews, the HR staff member stated she was new to her position and was responsible for completing orientation and paperwork, but was not aware that new hire training had not been completed as required for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos that included abuse/neglect, blood borne pathogens, HIV, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention, and said she was ultimately responsible for ensuring required training was completed during orientation, prior to employment, and annually. The DON stated she was responsible for ensuring nursing staff received required training during orientation, prior to employment, and annually.
Failure to Complete Required Resident Rights Training
Penalty
Summary
The facility failed to provide required education on resident rights and the responsibilities of a facility to properly care for its residents for 1 of 17 employees reviewed, CNA E. Record review of CNA E’s personnel file showed a hire date of 06/29/2024, and there was no evidence of annual training since the hire date on resident rights and facility responsibilities. Electronic training records showed CNA E initiated training on 04/15/2026, after surveyor entrance on 04/13/2026, but the training was not completed. During interviews, the HR Coordinator stated she was responsible for ensuring resident rights training was completed annually and upon hire, and said mandatory training should be completed on hire and annually so employees are knowledgeable. She acknowledged CNA E’s training was not completed annually as required by policy. The Administrator stated all mandatory training was required at the time of hire before staff started employment and annually thereafter, and said the risk of not completing resident rights training could cause the employee to not know what the rights were and could lead to violations. The DON stated she was responsible for monitoring incomplete training modules for nursing staff and said one reason for staff failing to complete training was a breakdown in communication. Facility policy revised 02/2026 stated all personnel must participate in initial orientation and regularly scheduled in-service training, and listed resident rights and responsibilities as a required training topic.
Missing Required Abuse and Dementia Training for CNA
Penalty
Summary
The facility failed to ensure that CNA E received required annual training on Abuse, Neglect, and Exploitation and dementia management. Record review showed CNA E was hired on 06/29/2024, and there was no evidence that the required annual training had been completed since her hire date. Electronic training records showed the training was initiated by CNA E on 4/15/2026 but was not fully completed after the survey team entered the facility on 04/13/2026. During interview, the HR staff member stated she was new to her position and was responsible for completing orientation and other paperwork, and she was not aware that CNA E had not completed the assigned training on Abuse, Neglect, and Exploitation and dementia management during annual training for 2025. The Administrator later reviewed the training file for CNA E and found no evidence of the required annual training. The facility policy revised 02/2026 stated that all personnel must participate in initial orientation and regularly scheduled in-service training, including training on preventing abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention.
CNA Annual In-Service Training Not Completed
Penalty
Summary
The facility failed to ensure that CNA E received the required minimum 12 hours of annual in-service education. Record review of CNA E’s personnel file showed a hire date of 06/29/2024 and no documentation of the required 12 hours of annual in-service training. The file also showed no training for 2025 in Resident Rights, Abuse, Dementia, Infection Control, Effective Communication, Falls, Restraints, or Behavioral Health. Electronic training records showed CNA E initiated training on 04/15/2026 after surveyor entrance on 04/01/2026, but the training was not completed. During interviews, the ADON, HR, Administrator, and DON each stated they were responsible for ensuring CNA training was completed and acknowledged that staff who did not receive the required training would not know how to care for residents. The facility policy revised 02/2026 stated that nurse aides are required to complete no less than 12 hours annually of in-service training, including topics such as resident rights, abuse, dementia, infection control, effective communication, falls, restraints, and behavioral health.
Failure to Provide Timely Incontinence and ADL Care Resulting in Poor Hygiene and Skin Issues
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance and timely incontinence care to a dependent resident, resulting in poor personal hygiene and skin issues. The resident was an older adult with type 2 diabetes, colostomy, hemiplegia of the right dominant side, an indwelling Foley catheter, and an ostomy, and was care planned as dependent on staff for toileting hygiene and at risk for skin integrity problems. His care plans directed staff to keep his skin clean and dry, provide incontinence care as quickly as possible after voiding or bowel movements, ensure he was clean, dry, and free from odor, and maintain his dignity and privacy. On the survey date, two CNAs entered the resident’s room to provide incontinence care and noted a strong urine odor. The resident was in bed on an air mattress, with contractures in both hands and long, dirty fingernails with a dark brown substance underneath. When linens were pulled back, a urine-soaked pillowcase with a strong odor was found between his thighs, and his groin and inner thighs were wet with redness noted to the mid-thigh. The underpad was wet with urine and had a brown ring extending to his upper back, and his back was entirely wet from urine. White, dried, flaky skin was observed around the base of his penis, and an old healed sacral wound with a small open area was noted. The CNAs cleaned his genital area and catheter tubing and placed a clean underpad, and both stated he would receive a shower. One CNA stated that the resident’s condition appeared as if he had not been changed during the previous night, noting the bad urine odor and that his entire bed was wet. She reported that residents were to be checked every two hours and that she had last showered him two days earlier, at which time he had no redness or open areas on his buttocks. The other CNA, on her fourth day at the facility, stated that the resident looked very raw with a bad rash down his legs and that the brown rings on the wet underpad indicated he had been in that condition for a long time; she confirmed that rounds were supposed to be done every two hours and that earlier in her shift she had only emptied his catheter drainage bag without providing incontinence care. The resident reported that staff had come into his room a couple of times the previous night when his catheter began leaking and had placed something between his legs, that this was the first time anyone had come in that morning, that he could tell when he was wet, and that he did not like having dirty nails. The DON and Administrator both stated that residents should be checked at least every two hours, that walking rounds should be done at shift change to ensure residents are clean and dry, and that nails should be cleaned when visibly soiled, and acknowledged that being left wet would be unacceptable and could lead to skin breakdown, infections, or mental anguish.
Failure to Assess and Report Incontinence-Related Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to skin assessment and incontinence care. The resident was an adult male with pneumonia, type 2 diabetes, and a right above-knee amputation, who was always incontinent of bowel and bladder and required extensive assistance with ADLs. His MDS and care plans documented bladder incontinence and potential for altered skin integrity, with interventions including incontinent care after each episode, weekly skin inspections, keeping skin clean and dry, and notifying appropriate staff of any new skin breakdown. At the time of survey, there were no documented active ulcers, wounds, or skin problems for this resident. During interview, the resident reported frequently waiting 30 minutes to an hour for incontinent care, stated he was currently wet and had not been changed that day, and described pain and itching around his genitals. He reported that staff often answered his call light and said they would return but did not come back. Observation of incontinent care by CNAs showed appropriate technique during that episode, but the resident’s scrotum was reddened and open wounds were visible on his right thigh/groin area. The charge nurse initially stated the resident had no active skin integrity issues and that no new concerns had been reported, and the treatment nurse also reported being unaware of any open wounds or active wound care orders for this resident. Further interviews revealed that a CNA had observed redness to the resident’s genitals and surrounding skin for about a week but did not report it to nursing staff, instead applying barrier cream on her own because the redness “comes and goes.” This was contrary to facility expectations and prior in-service education that CNAs immediately report any skin integrity concerns, including redness and rashes, to nursing staff. When the treatment nurse subsequently assessed the resident, she identified open wounds on the right inner thigh and redness to the scrotum, and a skin assessment documented new in-house moisture-associated skin damage/incontinence-associated dermatitis measuring 10 cm by 10 cm. Facility policies and in-service materials required perineal care to prevent infection and skin irritation and to observe skin condition, and directed staff to notify the wound care nurse immediately for new wounds, rashes, redness, or any abnormal skin finding, which did not occur in this case.
Improper Use of Mechanical Lift During Dependent Resident Transfer
Penalty
Summary
The facility failed to ensure a resident’s environment remained as free of accident hazards as possible when staff did not properly and safely use a mechanical lift during transfers. The resident was an elderly woman with Alzheimer’s disease, expressive language disorder, osteoporosis, and documented ADL self-care performance deficits and limitations in physical mobility. Her care plan and MDS indicated she was dependent on staff for all ADLs, including transfers, and required a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs applied the sling and used the mechanical lift to move the resident from bed to wheelchair. CNA B widened the base and placed the lift under the bed, but did not lock the wheels before lifting the resident. After elevating the resident, CNA B closed the legs of the lift, moved it to the wheelchair, then widened the base again and began lowering the resident. As the resident was being lowered, one of the lift’s wheels lifted off the floor, and CNA B stood on the lift to force the wheel back into contact with the floor while CNA A guided the resident into the wheelchair. In interviews, CNA B stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was usually the only one available because the other two battery-operated lifts were never fully charged. She reported she had informed the DON that the lift’s wheels could not be locked and that the lift had been in this condition since she started working there about three months earlier. She also stated she had previously refused to use the lift but felt she was treated as lazy when she did so. CNA A reported she did not notice that the wheels were not locked and was not aware of any problem with the locks. The DON stated that two staff were required for mechanical lift use, that residents should be secured with one staff operating the lift and one guiding it, and that the wheels should be locked once in position. The Administrator stated staff should not use mechanical lifts if the locks did not work and should report issues to nursing, Maintenance, or the DON. The facility’s “Safe Lifting and Movement of Residents” policy required staff to be trained in the use of mechanical lifting devices and to be observed for competency and adherence to policies and procedures regarding safe equipment use.
Failure to Ensure Competent and Safe Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff, specifically a CNA, had appropriate competencies and skill sets to safely use a mechanical lift for resident transfers. A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and significant ADL self-care and mobility deficits was care planned and assessed as dependent for all ADLs and requiring a Hoyer lift with two staff for transfers. On the observed date, two CNAs entered the resident’s room to transfer her using a mechanical lift, applied gloves, positioned the lift under the bed, and attached the sling that was already under the resident to the lift. During the transfer, CNA B did not lock the wheels of the mechanical lift before raising the resident from the bed. After lifting the resident, CNA B closed the legs of the lift, moved it to the wheelchair, then widened the base again and began lowering the resident. As the resident was being lowered, one of the lift’s wheels came off the floor, and CNA B stood on the lift to force the wheel back into contact with the floor while CNA A guided the resident into the wheelchair and detached the sling. CNA B later stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was typically the only one available because the other battery-operated lifts were never fully charged. CNA B reported she had been trained in mechanical lift use in the past, had informed the DON that the lift’s wheels would not lock, and that the lift had been in this condition since she started working at the facility about three months earlier. She also stated she had previously refused to use the lift but felt she was treated as lazy when she did so. The DON stated that two staff were required for mechanical lift use, that wheels should be locked when positioning, and that staff had competency check-offs on hire, as needed, and annually; however, she could not locate a mechanical lift competency checklist for CNA A and record review showed CNA B had no skills check-off on hire and none was provided before survey exit. Facility policy required facility- and resident-specific competency evaluations upon hire, annually, and as deemed necessary based on the facility assessment.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure staff followed its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with a chronic wound. The resident was an older adult with dysphagia, hypertension, and a history of cerebral infarction, and had severe cognitive impairment with a BIMS score of 3. The resident’s care plan, revised in November 2025, documented a stage 4 pressure ulcer on the right lateral ankle and required EBP, including gown and gloves, during high-contact care. Physician orders and the facility’s order listing confirmed an active order for EBP beginning in November 2025, and an EBP sign was posted on the resident’s door. On the observed date, CNA A entered the resident’s room, where the EBP sign was posted, and provided incontinent care and dressing without wearing a gown, using only gloves. She dressed the resident and repositioned her in bed, then removed her gloves, discarded them, exited the room, and sanitized her hands. In a subsequent interview, CNA A stated she was unaware the resident was on EBP, did not notice the sign, and expected PPE to be available in the hallway, which it was not. She acknowledged that gown and gloves should be worn for residents on EBP during care such as dressing. The DON and Administrator both confirmed that the resident was on EBP, that gowns and gloves were required for high-contact care including dressing, and that the DON, as the Infection Preventionist, was responsible for ensuring staff were trained on infection control. The facility’s written policy on Personal Protective Equipment–Enhanced Barrier Precautions specified that gown and glove use is required during high-contact resident care activities, including dressing, for residents with chronic wounds.
Failure to Revise Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and develop and implement effective fall-prevention interventions for a cognitively impaired resident with a significant history of falls. The resident was an older male with metabolic encephalopathy, lack of coordination, bipolar disorder with psychotic features, muscle weakness, muscle wasting and atrophy, a lumbar compression fracture, and a documented history of falls. His quarterly MDS showed a BIMS score of 6, indicating moderate cognitive impairment, and he required partial to moderate assistance with sit-to-stand and bed-to-chair transfers. The care plan identified him as high risk for falls due to confusion, impaired balance, incontinence, unawareness of safety needs, narcotic and psychotropic medication use, poor balance, and unsteady gait, and noted that he would attempt to transfer from bed to chair without assistance. Despite this high fall risk, record review showed the resident experienced repeated falls over several months, including multiple falls on the same day and both witnessed and unwitnessed events in his room and other facility areas. Facility documentation listed numerous falls across June, July, August, and September, including six separate falls on one date and at least two falls with injury, one of which resulted in a laceration and another that led to EMS transport and hospital evaluation for altered mental status. EMS and hospital records noted a known history of multiple falls and visible bruising in various stages of healing, including to the face and a bandaged wound to the forearm. Interviews with staff and family confirmed that the resident had frequent falls and multiple bruises over his body from these events. Interviews revealed that the resident was described as impulsive, defiant at times, and often refused to use his call light, instead attempting to transfer himself, particularly to go smoke. The Administrator, DON, ADON, LVN, and CNAs reported that the resident would “throw himself” during transfers from bed to chair or chair to bed and that most falls occurred when he attempted to transfer without assistance, often from wheelchair to bed. Staff stated that interventions in place included lowering the bed, placing fall mats, ensuring call lights were in reach, rearranging the room, frequent checks, therapy involvement, pharmacy reviews, and, at times, one-on-one supervision when behaviors were “really bad.” However, the DON acknowledged that, despite a fall timeline showing multiple recurrent falls, there were no new interventions implemented with each fall. The facility’s own fall policy required assessment after each fall, identification of causes and patterns within 24 hours, and modification of interventions when falls recurred, but the record review and interviews showed that interventions were not consistently revised in response to the resident’s ongoing falls and behaviors. Additional interviews indicated gaps in staff training related to behavioral management for residents with challenging behaviors. CNA A, who frequently cared for the resident, reported that she had not been trained on the facility’s policy related to residents with behaviors, although she had EMT training from outside the facility. LVN A also stated she had not received behavioral training at the facility, relying instead on prior nursing experience. Staff and administration reported that the resident’s behaviors and falls worsened after the family installed cameras in his room and the family member began waking him for smoke breaks and speaking to him through the camera, which prompted him to attempt transfers despite his weak legs and dementia. The combination of the resident’s high fall risk, repeated falls with injuries, lack of consistent modification of interventions after each fall, and incomplete behavioral-specific training for staff led to the identified deficiency in providing adequate supervision and assistive devices to prevent accidents. The facility’s written policy, “Assessing Falls and Their Causes,” required that after each fall, staff assess the resident, identify potential causes and patterns within 24 hours, and modify interventions when falls continued despite existing precautions. However, the DON’s review of the fall timeline and her statement that there were no new interventions with each fall demonstrated that this policy was not followed for this resident. Staff interviews consistently described the resident as frequently falling, having multiple bruises, and being known to throw himself during transfers, yet the interventions remained largely unchanged over time. This failure to adjust the care plan and interventions in response to the resident’s ongoing falls and behaviors, in the context of his complex medical and cognitive conditions, formed the basis of the deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.
Failure to Protect Resident From Physical Abuse and to Report and Investigate Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired male resident from physical abuse and to ensure staff were trained and knowledgeable in responding appropriately to resident behaviors. The resident, with metabolic encephalopathy, bipolar disorder with psychotic features, lack of coordination, muscle weakness, muscle wasting and atrophy, a lumbar vertebral compression fracture, a history of falls, and a BIMS score of 6 indicating moderate cognitive impairment, required supervision or assistance with personal hygiene, transfers, bed mobility, toileting, dressing, and bathing. Nursing documentation shows that on one morning the resident was yelling loudly and continuously in the hallway, and when a CNA entered his room, he was irritated and agitated, struck the CNA four times, and attempted to strike her in the face. The CNA reported grabbing the resident’s arm to prevent being struck, after which the resident pulled his arm away, resulting in a skin tear. Later that day, nursing documentation identified a 5 cm x 2.5 cm skin tear on the resident’s left forearm, which was treated, and the NP and Administrator were notified. The resident’s family member reported being notified that a CNA had grabbed the resident’s arm and caused a laceration during ADL care in his room and stated that video she viewed showed the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. CNA A stated that the resident had severe behavioral issues, including screaming, yelling, throwing objects, hitting staff, and attempting to break things, and that he often required one-on-one attention. She described an incident in which the resident struck her multiple times in the chest during ADL care, and she reacted by grabbing his hand and blocking him from hitting her again, which caused a small skin tear on his arm. She indicated she was unsure if an investigation had been done and that she had not been suspended after the incident. The Administrator stated she was on vacation when notified that CNA A had grabbed the resident’s arm, causing a skin tear, and that the DON was the assigned abuse coordinator and should have reported the incident to the state. She acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and said she assumed the DON had reported it. She also stated that a state surveyor later told her she did not need to report it. LVN A reported that the resident had moderate dementia with behavioral disturbances that escalated with family involvement and camera installation, and confirmed witnessing the resident attempt to hit CNA A, who then grabbed his hand, causing a skin tear, and that she reported the incident to the DON and Administrator. Both CNA A and LVN A stated they had not received behavioral training at the facility, despite the facility’s Abuse Investigation and Reporting policy requiring all alleged violations involving abuse, neglect, or injuries of unknown source to be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, and requiring a thorough internal investigation and timely notification of outcomes.
Failure to Timely Report Alleged Abuse Involving Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired male resident with multiple medical conditions, including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls. The resident required extensive assistance with transfers, bed mobility, toileting, dressing, and bathing, and had a BIMS score of 6, indicating moderate cognitive impairment. On the date of the incident, nursing documentation noted the resident was heard screaming loudly and continuously; a CNA entered the room and reported that the resident appeared irritated and agitated, screamed at her, struck her four times, and attempted to strike her in the face. The CNA stated she grabbed the resident’s arm to prevent injury to herself, and the resident pulled his arm away, resulting in a 5 cm x 2.5 cm skin tear to the left forearm. Subsequent nursing documentation recorded discovery and treatment of the skin tear, including cleansing with normal saline, application of steri-strips, and notification of the NP and the administrator later that day. The resident’s family member reported being notified by the facility that a CNA had grabbed the resident’s arm and caused a laceration during ADL care, and stated she had video showing the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. Interviews with staff confirmed the physical interaction: the CNA reported that during ADL care the resident struck her multiple times in the chest, and she reacted by grabbing his hand to block further hits, which caused a small skin tear. An LVN who was present stated she saw the resident attempt to hit the CNA, who then grabbed the resident’s hand, causing the skin tear, and reported the incident to the DON and administrator. The administrator stated she was on vacation and out of the country when she was notified of the incident involving the CNA grabbing the resident’s arm and causing a skin tear. She identified the DON as the assigned abuse coordinator and said the DON should have reported the incident to the state, but acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and assumed the DON had called the incident into the state. The CNA and LVN both indicated they reported the incident to the DON and administrator, and the CNA identified the administrator as the facility’s abuse coordinator. Review of the facility’s Abuse Investigation and Reporting policy, revised July 2017, showed that all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, including the State Survey Agency. The facility failed to ensure this allegation of abuse was reported within the required two-hour timeframe as required by federal and state regulations and facility policy.
Failure to Revise Care Plan for Falls, Behaviors, and Naloxone Use
Penalty
Summary
Surveyors identified a failure to revise and implement a comprehensive, person-centered care plan for a male resident with metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, muscle weakness, and a history of repeated falls. The resident had a BIMS score of 6, indicating moderate cognitive impairment and impaired safety awareness, and required extensive assistance with ADLs and transfers. Facility fall tracking showed numerous falls over several months, including multiple falls on the same day, reflecting ongoing unsafe transfer attempts, impulsive behavior, and poor safety awareness. Although the care plan identified the resident as high risk for falls and listed general fall-prevention measures, it was not updated with new or individualized interventions despite the continued pattern of falls and documented injuries such as skin tears, abrasions, periorbital bruising, and a laceration. The resident also had a care plan for Risperdal use related to bipolar disorder with severe psychotic features, but this plan only directed staff to monitor and record target behaviors and did not include individualized interventions for behavioral escalation, impulsivity, or aggression during care. The care plan lacked guidance on de-escalation techniques or safe response strategies during combative episodes, even though interviews with a CNA and an LVN confirmed the resident frequently became agitated, attempted to strike staff, and threw himself during transfers. Additionally, the MAR showed an active order for PRN Naloxone (Narcan) nasal spray and a requirement to monitor each shift for signs and symptoms of opioid overdose, yet the care plan did not address suspected overdose or changes in condition requiring emergency response, nor did it provide instructions on when or how to respond to suspected overdose. The DON acknowledged that no new interventions were added to the care plan despite recurrent falls and behavioral concerns, and no care plan policy was provided upon exit.
Failure to Administer Ordered Naloxone for Suspected Opioid Overdose
Penalty
Summary
Facility nursing staff failed to administer ordered naloxone (Narcan) to a cognitively impaired male resident when he was found unresponsive but breathing, despite having a standing PRN order for intranasal naloxone for suspected opioid overdose. The resident’s medical record showed multiple diagnoses including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls, with a BIMS score indicating moderate cognitive impairment and a need for assistance with transfers. The MAR for the month documented a standing order for naloxone nasal spray to be given every 2 minutes as needed for suspected opioid overdose, as well as an order to monitor each shift for signs and symptoms of opioid use or overdose, with staff consistently documenting that no such signs were present. On the date of the incident, EMS was called for the resident being unresponsive; upon EMS arrival, facility staff reported that Narcan had not been administered. EMS documentation showed that the resident was unresponsive on EMS arrival and that two doses of intranasal naloxone were administered, after which the resident became alert and verbally responsive, with stable vital signs. EMS notes also recorded that an unknown nurse reported no narcotic medications had been given by the facility and that staff suspected the family might be providing drugs during visits, with a known history of substance abuse prior to admission. A CNA reported having prior suspicions that the family was bringing in street drugs, noting that the resident’s condition would change and he would become unresponsive after family visits, and that she had previously observed EMS administer Narcan with immediate improvement. An LVN confirmed that staff suspected possible drug use or opioid toxicity based on the resident’s history and symptoms of unresponsiveness and lethargy, but stated they waited for EMS because they were unsure if it was safe to give Narcan. The DON confirmed Narcan was available in the Omnicell, staff had been trained, and facility policy directed staff to call 911 and administer naloxone when opioid overdose was suspected, but it was not administered by facility staff before EMS arrival in this event.
Failure to Include PICC Line Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a PICC line for intravenous access. Despite physician orders for regular PICC/Midline dressing changes and the presence of the PICC line, the resident's care plan did not include any interventions or maintenance instructions related to the PICC line. The care plan only addressed antibiotic therapy for infections but omitted the specific needs and care associated with the resident's IV access. Interviews with facility staff, including the MDS Coordinator, Director of Clinical Operations, and Administrator, confirmed that the care plan was incomplete and did not reflect the resident's current needs regarding the PICC line. The staff acknowledged that the omission could result in the resident not receiving necessary care. Facility policy requires that care plans be comprehensive, person-centered, and updated as resident conditions change, but this was not followed in this instance.
Failure to Change PICC Line Dressing per Physician Order
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of parenteral fluids by not managing a resident's PICC line dressing according to professional standards and physician orders. The resident, who had multiple diagnoses including UTI, type 2 diabetes, vascular dementia, hypertension, and hemiplegia, was admitted with an order for PICC/Midline dressing changes using sterile technique every 7 days or as needed if the dressing became wet or soiled. Observations revealed that the PICC line dressing was dated 10 days prior, exceeding the 7-day interval specified in the physician's order and facility policy. Interviews with staff, including an LVN, ADON, Director of Clinical Operations, and the Administrator, confirmed that only RNs were permitted to change PICC line dressings and that the dressing had not been changed as required. The staff were not aware that the dressing change was overdue until it was pointed out during the survey. The facility's policy and the physician's order both required dressing changes at least every 7 days, but this was not followed for the resident in question. The failure to change the dressing as ordered was acknowledged by multiple staff members, who also recognized that not adhering to the schedule could place residents at risk for infection.
Failure to Provide Required Hair Care and Scheduled Hygiene Services
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including personal hygiene and grooming, did not receive necessary hair care and scheduled showers or baths. The resident, who had multiple diagnoses such as cognitive communication deficit, muscle wasting, Parkinson's disease, diabetes, dementia, and major depressive disorder, was assessed as requiring assistance with personal care and was dependent for showers and partial/moderate assistance with hair care. Despite these needs, documentation showed missed or incomplete records for scheduled showers and personal hygiene, with several days lacking any documentation or indication of care provided. There was also no documentation specific to hair care, and no refusals were noted in the records for the relevant period. The resident developed a large mat of hair at the back of her head, which had to be cut out. Family concerns were raised when a family member discovered the hair mat during a visit and noted that she had not been notified of any refusals for showers. Staff interviews revealed that the resident often refused showers and hair care, preferring bed baths, but when bed baths were provided, hair care was not performed. Staff also admitted to sometimes missing documentation of refusals and not always informing the charge nurse as required. The care plan did not include specific interventions for hair care refusals, and there was a lack of consistent documentation and communication regarding the resident's refusals and the care provided. Interviews with nursing and administrative staff confirmed that the expectation was for residents to receive scheduled showers and hair care, and that refusals should be documented and reported. However, staff were not consistently aware of the resident's refusals or the lack of hair care, and notifications to family members were not made until after the issue was identified. The facility's own policy required documentation of care provided, refusals, and notification of supervisors, but these procedures were not followed, resulting in the resident not receiving necessary grooming and hygiene services.
Failure to Document ADL Care and Refusals in Resident Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for a resident who required assistance with activities of daily living (ADLs), specifically regarding documentation of baths, showers, hair care, and refusals of care. The resident, who had multiple diagnoses including cognitive communication deficit, muscle wasting, Parkinson's disease, diabetes, dementia, and major depressive disorder, was dependent on staff for personal hygiene and bathing. The care plan indicated the need for extensive assistance with bathing or showering at least three times weekly, and interventions were in place to notify a family member in case of refusals. However, there was no intervention specific to hair care refusals or documentation. Record reviews revealed multiple dates with missing documentation for both personal hygiene and bath/shower care, as well as a lack of documentation regarding hair care and refusals. Comprehensive CNA Shower Review sheets also lacked entries for hair washing on several dates. Nurse progress notes did not include any documentation of refusals for baths, showers, or hair care. Interviews with staff confirmed that the resident often refused showers and hair care, but these refusals were not consistently documented, and staff sometimes failed to notify the charge nurse as required by facility policy. The facility's policy required all services provided, progress toward care plan goals, and any changes in the resident's condition to be documented in the medical record, including refusals and notifications to family or physicians. Despite this, staff interviews and record reviews confirmed that documentation was incomplete or missing for several scheduled care events, and refusals were not properly recorded or communicated, resulting in a failure to maintain clinical records in accordance with accepted professional standards.
Failure to Notify Physicians and Obtain Timely Wound Care Orders Following Changes in Resident Condition
Penalty
Summary
The facility failed to promptly notify physicians and obtain appropriate wound care orders when residents experienced changes in condition, specifically related to pressure injuries. For three residents reviewed, there were significant lapses in communication and documentation. One resident developed an unstageable pressure injury to the right heel, but the wound care physician was not notified until two days after the injury was identified, and there was no documentation of physician notification or wound care orders on the day the wound was discovered. Additionally, after a surgical debridement, the facility did not contact the surgeon or wound care physician to obtain updated wound care orders. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but the facility did not obtain or implement wound care orders until several days after admission. Documentation showed that while the resident's physician was notified of the admission, there was no evidence that the wounds were reported or that wound care orders were requested at that time. For a third resident, the facility failed to monitor and report the status of a stage 4 pressure ulcer to the wound care physician, and there were gaps in the completion of required skin assessments. Interviews with staff revealed ongoing issues with accountability and follow-through regarding skin assessments and wound care. The facility did not have a dedicated treatment nurse, and regular nursing staff were responsible for these tasks, leading to inconsistent completion of assessments and treatments. Staff also reported confusion about when and how to notify physicians and document changes, and there was a lack of clear processes for ensuring timely physician notification and order implementation when residents' conditions changed.
Removal Plan
- Contact the facility wound care consulting provider to ensure no information had been relayed regarding the residents currently under care.
- Discuss Residents #11, #12, and #13 with the MDS Coordinator and the Assistant Director of Clinical Operations; ensure no new orders are needed.
- Contact the consulting wound care physician and inform of the resident being seen by the surgeon, debridement, and wound deterioration.
- Contact the resident representative and inform of the debridement, deterioration of the wound, and ask which consulting wound physician is preferred.
- Contact the wound care consulting physician to inform of the most recent measurements and wound condition for Resident #12.
- Compare wound measurements and condition for Resident #13 to previous observations and notify the wound care consulting physician.
- Notify the resident representative for Resident #13.
- Compare all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- Re-educate all nurses present regarding when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care, and how to contact the wound care consulting physician.
- Continue in-service until all nurses have been in-serviced and provide re-education prior to beginning their next scheduled shift.
- Review the 24-hour report to ensure a progress note is written when the wound care physician visits each resident and when the wound care physician is contacted to update with changes in wound condition.
- Provide education to all nurses regarding the completion of the Skin Issues evaluation when a new wound is discovered or when a resident is admitted with a wound, to notify the Director of Nurses and Facility Administrator, to notify the attending physician and/or the consulting wound care physician to obtain treatment orders and begin treatment orders immediately upon receipt, to make a notation on the 24-hour report of the new wound and to inform the Certified Nurse Aides of the residents wound and any changes needed for the residents plan of care.
- In-service nurses regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility.
- Re-educate nurses regarding notification of the physician when there is a change in condition of a wound and remind to document all physician interaction in the electronic health record.
- Replace the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers.
- Hold a daily stand-down meeting by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
- Conduct an impromptu QAPI meeting with the Facility Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations and Assistant Director of Clinical Operations.
- Ensure all residents have a current skin assessment completed and documented in the electronic health record and all residents with wounds are evaluated to ensure all appropriate interventions are in place and the attending physician and consulting wound care physician have been notified.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure injuries for four residents. For one resident, weekly skin assessments were not completed after a certain date, and there was a delay in obtaining and implementing wound care orders after an unstageable pressure injury was identified. Additionally, dietary recommendations from the dietician were not implemented, and wound care treatments were missed on multiple days, with no documentation of resident refusal. Another resident was admitted with bilateral stage 4 pressure injuries to the heels, but wound care orders were not obtained or implemented until several days after admission, and head-to-toe skin assessments were not completed as required. Wound care was also missed on several days for this resident. A third resident experienced deterioration of an existing pressure wound, which progressed from stage 3 to stage 4 and increased in size. Wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a certain date. An intervention for a low air loss mattress, as specified in the care plan, was not implemented. For a fourth resident, wound care was not performed as ordered for ten days, and weekly skin assessments were not completed after a specific date. There was no documentation that this resident refused treatment for her wound. Observations and interviews revealed that staff were not consistently performing or documenting required skin assessments and wound care. The facility did not have a designated treatment nurse, and floor nurses were responsible for wound care and assessments, but these tasks were often not completed as scheduled. Staff interviews indicated a lack of accountability and follow-through, with missed documentation and communication lapses regarding wound care orders and changes in resident condition. Facility policies required notification of the attending physician for new skin alterations and evaluation and documentation of skin changes, but these procedures were not consistently followed.
Removal Plan
- Dietary recommendations for Resident #11 were approved with orders written.
- Consulting wound care physician was contacted by the Corporate Director of Clinical Operations regarding Resident #11's wound and treatment orders.
- Resident representative for Resident #11 was contacted to determine preferred wound care physician.
- Resident #11 scheduled to be seen by the wound care physician.
- Wound care consulting physician was contacted by the Corporate Director of Clinical Operations regarding Resident #12 to inform of most recent measurements and wound condition.
- Resident representative for Resident #12 was notified of current wound condition by the MDS Coordinator.
- Admitting nurse for Resident #12 was provided with individual education regarding ensuring residents admitted with a wound have orders for treatment, notifying the physician, and immediately rendering treatment upon admission.
- Wound care consulting physician was notified by the MDS coordinator regarding Resident #13's wound condition.
- Resident representative for Resident #13 was notified by the MDS Coordinator.
- All nursing staff present at the time of notation were provided with an in-service on how to document when a resident is not available for a visit by a consulting provider.
- Facility MDS coordinator evaluated all current wounds, measured wounds, and documented the condition of all wounds in the Skin Issue evaluation of the electronic health record.
- Nursing administration team compared all measurements and wound condition observations to previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician.
- All nurses present at the time of notification were re-educated in the form of an in-service regarding completion of weekly skin assessments, including how to complete the assessment, what to look for, when to complete the assessment, what to document, and when to report skin issues.
- Nurses will be provided with notification of consequences for failure to complete scheduled skin assessments during their shift.
- Completion of skin assessments will be monitored by the Director of Nursing and by the designated Weekend Nursing Supervisor.
- A complete head to toe skin inspection was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Assistant Corporate Director of Clinical Operations on all residents.
- Nurses present at the time of notification were in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician, obtaining orders for treatment, ensuring orders for treatment are initiated immediately, and inquiring about existing wounds when receiving report from the discharging facility.
- Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Facility Administrator were re-educated on reviewing the missing documentation report for the Treatment Administration Record from the electronic health record.
- The missing documentation report for Treatment Administration Records will be reviewed by the Director of Nursing during the morning clinical meeting.
- Facility Administrator will ensure review of missed documentation report, admission record review, admission order reconciliation, and review of the 24/72-hour report.
- Facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management.
- Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service.
- Facility Administrator and Administrative Nursing Team will review the nursing schedule to ensure one designated nurse is scheduled to review wounds, complete measurements, evaluate wound condition and prepare the weekly skin report at least once per week.
- Weekly skin report will be reviewed by the Administrative Nursing Team and the Facility Administrator to ensure all interventions are present including supplements/vitamins as recommended by the registered dietician, support surfaces are appropriate, and treatments are evaluated for effectiveness.
- Weekly skin report review meeting will occur on Tuesday of each week.
- The Assistant Director of Nursing will divide daily treatments/wound care between the day shift and night shift to allow floor nurses more time to complete the treatment/skin assessment processes.
- A daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately.
Significant Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission and improper administration of critical medications for two residents. For one resident, Metoprolol and Entresto, both prescribed for hypertension and heart failure, were not administered as ordered on a specific evening. Additionally, upon admission from the hospital, Entresto was not ordered for another resident, despite it being listed on the hospital discharge medication list. This omission was not identified or corrected by the admitting nurse or subsequent staff responsible for medication reconciliation and order entry. The same resident also failed to receive Eliquis, an anticoagulant prescribed for atrial flutter, on eight occasions in a single month. The medication administration record (MAR) showed multiple blanks with no documentation to indicate whether the medication was given or refused. Interviews with nursing staff revealed inconsistent documentation practices, with some staff admitting to forgetting to chart medication administration or not following up on missed doses. There was also a lack of clarity and communication regarding the process for documenting refusals and ensuring that all medications were administered as ordered. The resident who missed multiple doses of Eliquis was later hospitalized and diagnosed with atrial fibrillation with rapid ventricular response, acute on chronic systolic and diastolic heart failure, and a small pulmonary embolus. Staff interviews indicated that the resident was sometimes noncompliant or refused medications, but there was no consistent documentation of refusals or evidence that appropriate notifications were made to the physician or family. The facility's policies required that all medication refusals or omissions be documented in the MAR, but this was not consistently followed, leading to significant medication errors.
Removal Plan
- The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted to ensure no residents are in jeopardy or threat of harm.
- Chart reviews of the remaining residents admitted and re-admitted will be completed by the administrative nursing team with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record.
- Chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record.
- The Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process.
- The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible.
- All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing.
- The staff in-service will be conducted by the Administrative Nursing Team and will continue until all nurses and certified medication aides have been provided with the beforementioned education; the remaining nurses and certified medication aides will be educated prior to beginning their next shift.
- All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift.
- A QAPI meeting was conducted with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed.
- The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations and discussed the alleged deficient practice; it was decided that all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday.
- The Consultant Pharmacist will review all residents admitted /re-admitted to the facility. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out.
- The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes.
- The Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday.
- The facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin a full audit of all resident medication orders.
Failure to Provide Timely Assessment and Documentation After Falls and Skin Issues
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice for four residents reviewed for quality of care. In one instance, a resident with dementia, osteoporosis, hypertension, and atrial fibrillation experienced a fall and hit her head. The care plan required immediate assessment, vital signs, and neuro checks, as well as notification of the physician and family. However, the assigned RN did not promptly assess the resident, did not conduct or document a neuro assessment, and failed to notify the physician and family in a timely manner. The incident was not documented in the 24-hour report, and the required incident report was not completed. The RN admitted to not documenting her actions and leaving work without completing the necessary paperwork, and the resident was not sent to the ER until the following day after further assessment by another nurse. Additionally, the facility failed to ensure that head-to-toe skin assessments were completed by a nurse after a CNA identified possible ant bites on three residents. Although the CNA reported the findings to the nurse and ADON, there was no documentation of a nursing assessment or progress note for the affected residents on the dates the bites were identified. Weekly skin assessments were also not documented for these residents during the relevant periods. Interviews with staff confirmed that nurses were responsible for completing these assessments and that there was a lack of accountability and follow-through in ensuring that assessments were performed and documented. Observations and interviews with residents confirmed the presence of ant bites and issues with ants in their rooms. Staff interviews revealed that the facility did not have a dedicated treatment nurse, and that nurses were responsible for weekly and as-needed skin assessments. The ADON and Administrator acknowledged ongoing problems with staff not completing required assessments and documentation, and that there was no system in place to hold staff accountable for these lapses. Facility policy required immediate assessment and documentation after falls and new skin issues, but these protocols were not followed in the cited cases.
Failure to Administer and Document Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. Multiple instances were identified where ordered medications were not administered as scheduled, as evidenced by blank entries on the Medication Administration Record (MAR) for various dates. The missed medications included Levothyroxine, Calcium Carbonate, Cyclosporine drops, Tizanidine, Lyrica, Ativan, Atorvastatin, Toprol, Ramelteon, Ropinirole, Duloxetine, Entresto, and Topiramate. The MARs did not contain documentation or reasons for the missed doses, contrary to facility policy, which requires documentation if a medication is withheld, refused, or not given at the scheduled time. The resident involved was a female with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, and hypothyroidism. She required maximal assistance with most activities of daily living and had an intact cognitive status. Her care plan included interventions to administer medications as ordered for conditions such as hypothyroidism, restless leg syndrome, chronic pain, neuropathy, anxiety disorder, and other chronic conditions. During interviews, the resident reported increased pain levels when medications were missed, although she was unsure which specific medications were not received. Staff interviews revealed a lack of awareness or recall regarding the missed medications. Nursing and medication aide staff stated that any held or refused medications should be documented in the MAR and a progress note made, but the MARs reviewed showed unexplained blanks. The Assistant Director of Nursing acknowledged ongoing issues with staff accountability and documentation, and administrative staff were unaware of the specific missed medications but confirmed that the expectation was for medications to be administered as ordered. The facility's policy requires safe, timely administration of medications and proper documentation when medications are not given.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff during care of three residents. One certified nursing assistant (CNA) did not perform hand hygiene before donning gloves and failed to change gloves or sanitize hands when moving from dirty to clean tasks during incontinent care. The CNA also placed clean linens and a gown on the resident while still wearing contaminated gloves, contrary to facility policy and infection control standards. The CNA acknowledged during interview that these actions were incorrect and could lead to cross-contamination. A licensed vocational nurse (LVN) was observed performing wound care for a resident with a stage 4 pressure ulcer. The LVN did not change gloves or perform hand hygiene between cleaning the wound and applying a clean dressing, despite recognizing during interview that this was required to prevent infection. Facility records confirmed that the LVN had received training on proper wound care technique, including enhanced barrier precautions, prior to the incident. Additionally, the MDS Coordinator failed to wear a gown as required under enhanced barrier precautions while providing wound care to a resident with a chronic wound. The resident's care plan and physician orders specified the need for enhanced barrier precautions, including gown and gloves, during high-contact care. The MDS Coordinator admitted during interview that a gown should have been worn and that failure to do so could expose residents to infection. Facility policy and staff interviews confirmed that residents with chronic wounds require enhanced barrier precautions and that appropriate signage should be posted to indicate this requirement.
Failure to Hold Timely Interdisciplinary Care Plan Meeting with Resident and Representative
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was prepared and reviewed by an interdisciplinary team with the participation of the resident and her representative for one resident. The resident, who had diagnoses including major depressive disorder, type 2 diabetes, and hypertensive heart disease with heart failure, was admitted to the facility and was cognitively intact, as indicated by a BIMS score of 15. She required assistance with eating, oral hygiene, and was dependent on staff for toileting. The resident was actively involved in her assessment and goal setting. A review of records showed that the last care plan conference for the resident occurred in March, with both the resident and her representative in attendance. Although another care plan meeting was scheduled for June, it was not held because the resident was hospitalized at that time, and the meeting was not rescheduled. There were no further care plan conferences documented for the resident after March, and the resident and her representative were not invited to any subsequent meetings. Interviews with facility staff, including the MDS Coordinator, AD, DOR, and DM, confirmed that the resident missed her quarterly care plan meeting and that the oversight was not corrected. Staff interviews revealed that care plan meetings were typically held weekly, with each resident expected to have a meeting quarterly and as needed. The MDS Coordinator was responsible for scheduling and conducting these meetings, which involved the IDT and addressed all aspects of the resident's care. Staff acknowledged that missing care plan meetings could result in residents and their representatives not being informed or able to address concerns. The facility's policy required the IDT, in conjunction with the resident and their representative, to develop and implement a comprehensive, person-centered care plan, which was not followed in this instance.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an observation, it was noted that the dish machine was not reaching the required temperature of 120 degrees as per the manufacturer's guidelines. The temperature gauge on the dish machine did not exceed 108 degrees, and the Dietary Aide (DA) was unaware of how to check the temperature or where to find it. The Dietary Manager (DM) acknowledged the issue and mentioned that the dish machine had been reaching the required temperature according to the dish machine log, but agreed to contact the company for repairs. Additionally, the facility failed to remove expired and spoiled food items from the refrigerator. Observations revealed nine containers of yogurt with past expiration dates, and boxes of cabbages, onions, cucumbers, and tomatoes that were either moldy or had a strong, unpleasant odor. The DM was unaware of these items and stated that the cooks and tray aides were responsible for checking the refrigerators daily. The Registered Dietitian (RD) confirmed that all foods should be labeled, dated, and expired or old foods should be removed to prevent residents from consuming them. Interviews with staff revealed that the kitchen was short-staffed, making it difficult to check refrigerators and freezers daily. The Maintenance Supervisor was not aware of the dish machine issue until it was reported by the Administrator, and there was no maintenance logbook to track issues. The Administrator acknowledged the oversight responsibility and stated that the dietary manager had not informed her of the kitchen issues. The facility's policies required food service staff to be trained in dishwashing machine use and to report inadequate temperatures immediately, but these procedures were not followed, leading to the deficiencies observed.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the kitchen. Observations on February 24, 2025, revealed roaches crawling on the walls, floor, and even on a recipe binder near food preparation areas. The Dietary Manager (DM) acknowledged the presence of roaches and mentioned that pest control services were conducted monthly. However, the issue persisted, as evidenced by further observations on February 25, 2025, where roaches were found on the steam table and walls. The Administrator, upon witnessing the infestation, instructed the staff to clean the kitchen and serve lunch on paper plates that day. Interviews with staff and the pest control representative indicated that the facility had been experiencing issues with roaches for some time. The Pest Control Representative noted that the kitchen was a problem area due to loose food and catch basins that attracted roaches. Despite monthly treatments with various chemicals, the infestation continued. The Maintenance Supervisor, who had been in her role for three months, confirmed the ongoing issue and mentioned that the kitchen was cleaned and sprayed with a residual bug spray. The Administrator expressed concerns about the risk of foodborne illnesses due to the pest problem and emphasized the need for a clean and pest-free kitchen.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #167, a female with cellulitis, was admitted without a baseline care plan being completed. Her medical records indicated she was cognitively intact and required assistance with daily activities, had a diabetic foot ulcer, and was receiving treatment for an infection. Resident #174, admitted with a hip fracture, also did not have a baseline care plan implemented within the required timeframe. Resident #175, who was admitted with sepsis due to MRSA and had a surgical wound, did not have a baseline care plan initiated until several days after admission. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for ensuring baseline care plans were completed, with the weekend RN tasked with handling admissions during weekends. The MDS nurse acknowledged the importance of these care plans in communicating residents' needs and affecting discharge planning. The facility's policy, revised in December 2016, mandates that baseline care plans be developed within 48 hours of admission to meet residents' immediate care needs. The failure to adhere to this policy could result in staff not being adequately informed about how to care for the residents.
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 multiple instances of non-compliance with infection control practices. During meal service, a CNA did not wash or sanitize her hands between handling meal trays for different residents, which could lead to cross-contamination. Despite being aware of the need for hand hygiene, the CNA admitted to not receiving specific training on infection control during meal service. In another instance, a CNA did not wear the required personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions (EBP) due to a feeding tube. The CNA acknowledged the oversight and the potential risk of spreading germs to other residents. Similarly, another resident on contact isolation due to MRSA did not have appropriate signage, and staff entered the room without donning PPE, indicating a lack of awareness and adherence to isolation protocols. Additionally, staff failed to follow EBP protocols for a resident with a colostomy and urinary catheter, as observed when a nurse and a CNA provided care without wearing gowns. Despite training on infection control and PPE requirements, staff admitted to forgetting to use PPE, which could increase the risk of infections. The facility's policies on hand hygiene, PPE, and isolation precautions were not consistently followed, contributing to the deficiencies observed.
Failure to Provide Effective Communication Training to New Staff
Penalty
Summary
The facility failed to ensure that six new employees received the required training on effective communication during their orientation. The employees affected included two Licensed Vocational Nurses (LVNs), a Social Worker (SW), and three Certified Nursing Assistants (CNAs). The lack of training was identified through a review of employee files, which showed that these staff members had not completed the necessary training upon hire. This oversight was acknowledged by the Administrator, who admitted to being unaware of the training requirements. Interviews conducted during the investigation revealed that the Director of Nursing (DON) was not initially responsible for staff training, as this task was previously managed by the Assistant Director of Nursing (ADON). However, the DON recognized the potential risks associated with the lack of training, such as staff being unable to deescalate situations or effectively communicate with residents, particularly those with dementia. The facility's assessment tool highlighted the importance of training on effective communication, infection control, and dementia management, but these requirements were not met for the new employees in question.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures to five staff members, including an LVN, a social worker, and three CNAs, upon their hire. The staff members in question were hired between October 2024 and February 2025, but their personnel files indicated they had not completed the required training during orientation. This oversight was identified through interviews and record reviews conducted by surveyors. During interviews, the Administrator acknowledged a lack of awareness regarding the training requirements and accepted responsibility for ensuring all staff receive proper training on hire and annually. The Director of Nursing (DON) indicated that the Assistant Director of Nursing (ADON) had previously been responsible for staff training, but the DON would now assume this responsibility. The absence of training could potentially place residents at risk of infection due to staff not being adequately trained in infection control practices.
Failure to Complete Mandatory CNA Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed mandatory training in Abuse, Neglect, and Exploitation (ANE) and dementia management during their orientation. This deficiency was identified for three CNAs, referred to as CNA O, CNA P, and CNA Q, who were reviewed for training compliance. The record review of employee files revealed that these CNAs, hired on different dates, had not completed the required trainings during their orientation period. Interviews conducted during the investigation highlighted a lack of awareness and responsibility regarding training requirements. The Administrator admitted to not knowing that these trainings were mandatory, while the Director of Nursing (DON) acknowledged that the Assistant Director of Nursing (ADON) had previously been responsible for staff training. The DON expressed concern that residents could be at risk of being cared for by untrained staff. The Administrator also recognized her ultimate responsibility for ensuring proper training and acknowledged the potential increased risk of harm to residents if staff were not adequately trained.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory and effective behavioral health training for six employees, including two Licensed Vocational Nurses (LVNs), a Social Worker (SW), and three Certified Nursing Assistants (CNAs). These employees were not given the required behavioral health training upon hire, as stipulated by the facility's policy and regulations. The personnel files of these employees, hired between October 2024 and February 2025, showed no evidence of completed behavioral health training, which is essential for ensuring that staff can adequately care for residents with behavioral health needs. Interviews with the facility's Administrator and Director of Nursing (DON) revealed a lack of awareness and oversight regarding the training requirements. The Administrator admitted to not knowing that these trainings were mandatory and acknowledged her ultimate responsibility for ensuring staff received proper training. The DON indicated that the Assistant Director of Nursing (ADON) had previously been responsible for staff training, but she would now assume this responsibility. Both acknowledged that the absence of proper training could place residents at risk of being cared for by untrained staff.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically the diversion of Hydrocodone-Acetaminophen tablets. The incident involved Resident #17, a male with a history of cognitive impairment and other medical conditions, who was prescribed this narcotic pain reliever. The medication was reported missing on December 31, 2024, when it was discovered that a whole card of the medication was unaccounted for. Interviews with multiple staff members, including medical assistants, licensed vocational nurses, and registered nurses, revealed that the established procedure for receiving and verifying narcotic medications was not properly followed. The process required two nurses and the pharmacy delivery person to verify the medication count and sign off on the receipt, ensuring the medications were stored securely. However, discrepancies in the medication count were not identified at the time of delivery, and the medication was not appropriately secured, leading to its misappropriation. The Director of Nursing and the Administrator were informed of the missing medication and subsequently involved the police to investigate the incident. The facility's policies on medication delivery and abuse prevention were reviewed, highlighting the requirement for strict adherence to procedures to prevent such occurrences. Despite these policies, the failure to follow protocol resulted in the misappropriation of Resident #17's medication, compromising the resident's right to be free from such exploitation.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, specifically in relation to the cleanliness of a privacy curtain and a wheelchair. The resident, who was diagnosed with Alzheimer's disease, PBA, osteoporosis, and an expressive language disorder, was observed in a room where the privacy curtain had a large brown splatter stain, suspected to be feces, and the wheelchair had a strong urine odor. Staff members present during the observation acknowledged the issues and indicated that the night shift staff were responsible for cleaning the wheelchairs and cushions, but they were unsure about the cleaning schedule for the privacy curtains. Interviews with various staff members, including the Maintenance Supervisor, DON, and housekeeping staff, revealed a lack of clarity and consistency in the cleaning responsibilities and schedules for both the privacy curtains and wheelchairs. The Maintenance Supervisor admitted that there was no set schedule for cleaning the privacy curtains and that she was only made aware of the issue after it was reported. The Transport Driver, responsible for cleaning the wheelchairs, stated that he cleaned them monthly but did not have documentation to support this claim. Housekeeping staff were not consistently informed or trained about their responsibilities regarding the privacy curtains. The Administrator was unaware of the specific issues with the resident's environment but acknowledged that the Maintenance Supervisor and housekeeping staff were responsible for ensuring cleanliness. The facility's policy on cleaning and disinfection indicated that environmental surfaces should be cleaned according to CDC recommendations, but the lack of adherence to this policy contributed to the unsanitary conditions observed in the resident's room.
Failure to Conduct PASARR Level II Review for Resident with New Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed major depressive disorder for a Level II PASARR review following a significant change in condition. The resident, who was admitted with diagnoses including adjustment disorder with depressed mood, major depressive disorder, dementia, and osteoporosis, was discharged to a behavioral hospital and returned with a new diagnosis of major depressive disorder. Despite this, the facility did not complete a new Level 1 PASARR with the updated diagnosis, which is necessary to ensure the resident receives appropriate services. Interviews revealed that the MDS Coordinator, who was responsible for PASARR coordination, was unaware of the need to complete a form 1012 for further evaluation and did not complete the necessary documentation. The Director of Nursing and the Administrator were also not familiar with the PASARR process or the new diagnosis, leading to a lack of necessary evaluations and potential service provision for the resident. The facility's policy requires screening for mental disorders upon admission and readmission, but this was not adhered to in this case.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #1, a cognitively intact female with chronic obstructive pulmonary disease, required assistance with bathing due to physical mobility limitations. Despite her care plan indicating the need for extensive assistance with bathing at least three times weekly, records showed she was documented as having bathed herself on multiple occasions without proper staff assistance. During an interview, Resident #1 expressed that she had not received a shower or bed bath in over a year, and staff had not offered alternative bathing methods, such as a bed bath, which she desired. Resident #173, a female with a diagnosis of cerebral infarction, was observed with long, dirty nails and reported not having received proper nail care or a recent shower. Her baseline care plan emphasized the need for anticipating and meeting all her needs to ensure well-being and dignity. However, documentation lacked evidence of nail care, and during an interview, she expressed a desire to be clean. The Director of Nursing acknowledged the risk of infection from inadequate nail care and showers, and the Administrator noted the importance of following care plans to prevent residents from feeling dirty and to reduce infection risks.
Failure to Supervise Resident Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to smoking policies for a resident, leading to a deficiency in preventing accidents and hazards. Resident #27, who has diagnoses of dementia, pneumonia, and bipolar disorder, was observed with smoking materials in his possession, contrary to the facility's policy. The resident was supposed to return his lighter and cigarettes to the staff after smoking, but he was found with these items in his room and on his person. The facility's policy requires that smoking materials be stored securely and only accessed under supervision, which was not adhered to in this case. Observations and interviews revealed that Resident #27 had been keeping his smoking materials in a metal container and had access to tobacco stored in the activity room. The Director of Nursing (DON) and the Administrator confirmed that no residents were allowed to keep smoking materials in their rooms, and the materials should be locked away. The failure to enforce these policies and ensure the resident returned his smoking materials after use posed a risk of fire or injury, as acknowledged by the facility staff.
Failure to Document Drug Destruction Witness Signatures
Penalty
Summary
The facility failed to establish a comprehensive system for documenting the receipt and disposition of controlled drugs, which is essential for accurate reconciliation and compliance with pharmacy service policies. Specifically, during the months of January and February 2025, the facility did not document the required number of witness signatures for drug destruction. On January 28, 2025, the drug destruction records were signed only by the Director of Nursing (DON) and the Pharmacist, lacking the necessary additional witness signatures. Similarly, on February 20, 2025, the records were signed solely by the Pharmacist without any witness signatures. Interviews revealed that the DON was unaware that staff other than herself and the Assistant Director of Nursing (ADON) could serve as witnesses for drug destruction. The absence of an ADON in January and the oversight in February contributed to the failure to obtain the required signatures. The Administrator was not involved in the drug destruction process and was unaware of the missing signatures, acknowledging the risk of drug diversion due to the lack of proper documentation. The facility's policy, revised in April 2019, mandates at least two witness signatures for the destruction of controlled substances, which was not adhered to in these instances.
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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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