Vernon Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vernon, Texas.
- Location
- 4301 Hospital Dr., Vernon, Texas 76384
- CMS Provider Number
- 745007
- Inspections on file
- 7
- Latest survey
- August 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vernon Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A facility failed to protect residents from neglect during an emergency transfer, resulting in residents being stranded in extreme heat without adequate care. The transfer was conducted without nursing staff or medications, leading to hospitalizations for heat-related illnesses. The facility lacked communication and planning, with staff and family members uninformed about the closure and transfer process.
A facility failed to prevent neglect during a resident transfer, resulting in three residents being stranded in extreme heat for six hours without adequate care. The residents, who had severe cognitive impairments and health issues, were transported in a van that broke down and lacked necessary staff and provisions. Two residents required hospitalization for heat-related conditions, and one was found unresponsive. The facility did not notify families or agencies of the closure and lacked a proper closure plan.
During an emergency closure, the facility failed to ensure a safe transfer of residents, leading to a van breakdown in extreme heat without adequate care or water. Residents were given only 24 hours' notice, and the facility lacked a closure plan, resulting in hospital admissions for heat-related issues and inadequate support for residents and families.
The facility failed to notify two residents, their representatives, and the State LTC Ombudsman about their transfer or discharge. One resident's RP was informed of the facility's closure the day before, with no assistance offered for relocation. Another resident's RP was not notified by the facility and had to learn about the transfer from a family member. The DON was out of town and unable to provide policies, and the facility's owner confirmed an emergency closure due to staffing issues, with residents notified only a day prior.
The facility failed to implement an effective discharge planning process for two residents, leading to a deficiency in meeting their discharge goals and needs. One resident, with severe cognitive impairment, was transferred without proper notification to the family, causing distress. Another resident was informed of the facility's closure only a day before, leaving the family to arrange alternative accommodation without assistance. The DON was unaware of the transfers and expressed concerns about staffing shortages and lack of communication. The facility's policy on transfer and discharge was not followed.
The facility failed to maintain sufficient nursing staff, compromising resident safety and well-being. Despite efforts to address the issue, the owner acknowledged the staffing shortage, leading to the facility's closure. A nurse was unable to leave her shift due to lack of relief, and a bus driver, not a CNA, transported residents without nursing staff, violating the facility's staffing policy.
A facility failed to administer evening medications to three residents during transport to a new facility. One resident, with severe cognitive impairment, was hospitalized after not receiving his medication. Two other residents, with moderately impaired cognition, did not receive their medications due to a lack of nursing staff during transport. This failure to follow medication administration policy placed residents at risk of not receiving therapeutic benefits.
Two residents did not receive a normal evening meal during their transfer to another facility due to an emergency temporary closure caused by staffing issues. Instead, they were given half a sandwich, and no nursing staff accompanied them on the van. The van broke down, leaving the residents stranded for hours without adequate food. The facility's emergency disaster policy did not address the specific needs during the transfer.
The facility was without a licensed Administrator for 1.5 weeks, leading to mismanagement and unpaid bills affecting essential services like pest control and dietary supplies. The Owner, not licensed in Texas, failed to notify state authorities about closure plans. The DON and former Administrator reported significant operational issues, and the Medical Director was unpaid for over six months but continued to provide care.
The facility failed to have a licensed Administrator, as the Owner, who was acting in this role, did not hold a Texas license. The previous Administrator quit without notice, and the Owner did not notify HHSC or seek a replacement. The facility planned to close, transferring residents to a sister facility, while the DON assumed the role of Abuse Coordinator.
The facility failed to provide timely written notification of closure to residents and their representatives, affecting three residents. A resident with severe cognitive impairment was upset about the move, and his representative received no assistance in finding a new placement. Another resident learned about the closure from a peer, and his representative also received no guidance. A third resident's representative decided to take the resident home after being informed by an aide. The facility did not adhere to its closure policy, which required immediate notification to authorities and residents.
The facility failed to have a closure plan, resulting in abrupt notification to residents, families, and staff about the closure. The Owner, lacking a state Administrator license, decided to close the facility without notifying regulatory authorities or providing assistance to residents for relocation. Residents and their representatives were left to make their own arrangements, and the facility Medical Director was not informed until the day of closure.
The facility failed to provide timely access to personal funds for two residents with schizoaffective disorder, causing stress and financial difficulties. Both residents experienced significant delays in receiving their funds due to the resignation of the Business Office Manager and the facility's financial issues, which hindered their ability to manage their financial affairs as per the facility's policy.
The facility failed to maintain food service safety standards, with a dietary aide not wearing a hair net, dirty exhaust vent filters, and improperly labeled leftovers. Financial difficulties led to inadequate food supplies, with the Dietary Manager limited to $1000 per week and no emergency supplies maintained. Meals were improvised daily without a set menu, as confirmed by staff interviews.
The facility did not have a licensed administrator after the previous one quit without notice, and the owner, not licensed in Texas, failed to notify HHSC. The owner decided to close the facility and transfer residents, citing financial issues as the reason for the administrator's departure.
Neglect During Emergency Resident Transfer
Penalty
Summary
The facility failed to protect residents from neglect, resulting in an emergency transfer of residents without adequate preparation or notice. The facility lacked sufficient staff to provide care, leading to a hasty decision to transfer residents to another facility with only 24-hour notice to residents and their families. During the transfer, residents were placed in a van that was not in good repair, which broke down, leaving them stranded on the roadside for approximately six hours in extreme heat conditions. The transfer was conducted without nursing staff, medications, or provisions for resident care during the journey. As a result, two residents required hospitalization for heat-related illnesses after being exposed to high temperatures for an extended period. Another resident was found unresponsive due to the heat and lack of water, necessitating emergency medical services intervention. The facility's actions placed residents at risk of physical and emotional harm, as they were not adequately cared for during the transfer. Interviews with staff and family members revealed a lack of communication and planning regarding the facility's closure and resident transfers. The facility did not have an administrator, and the owner admitted to being aware of staffing issues for over a week before the closure. The facility's neglect policy and emergency closure policy were not followed, leading to a chaotic and unsafe transfer process for the residents.
Neglect During Resident Transfer Leads to Hospitalization
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect, resulting in significant harm to three residents during a transfer. The residents were transported in a van that was not in good repair and broke down, leaving them stranded on the roadside for approximately six hours. The van lacked necessary staff, medications, and provisions for resident care, exposing the residents to extreme heat without water or adequate supervision. Resident #1, a male with severe cognitive impairment and multiple health issues, including Alzheimer's disease and congestive heart failure, experienced syncope and was admitted to the hospital for heat exhaustion and possible seizure activity. Resident #3, also with severe cognitive impairment and dehydration, was lethargic and required hospitalization for dehydration and acute kidney injury. Resident #2, a female with dementia and cognitive decline, was found unresponsive due to heat exposure and required emergency medical services for evaluation. The facility's administration failed to notify residents, families, or state agencies of the emergency closure and transfer, and there was no closure plan in place. The Director of Nursing and other staff were informed of the closure only a day before the transfer, and the facility lacked an administrator and sufficient staff to manage the situation. The owner admitted to the lack of preparation and staffing issues, which led to the hasty and unsafe transfer of residents.
Unsafe Resident Transfer During Emergency Closure
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge of residents during an emergency closure, resulting in significant deficiencies. Residents were transferred in a van that was not in good repair, leading to a breakdown on the roadside for approximately six hours. This incident occurred in extreme heat conditions, with outside temperatures reaching up to 107 degrees Fahrenheit. The residents were left without water and adequate care during this time, leading to heat-related episodes and hospital admissions for some residents. The facility did not provide sufficient notice or assistance to residents and their families for the transfer. Residents and their responsible parties were only given 24 hours' notice of the facility's closure, leaving them with inadequate time to make necessary arrangements. Additionally, the facility did not have a closure plan in place, and there was a lack of communication with residents, families, and state agencies. The facility also failed to provide emotional and psychological support to residents and families during the relocation process. Specific residents were adversely affected by these deficiencies. One resident, with severe cognitive impairment and multiple health issues, was transferred without the responsible party being notified. Another resident, also with severe cognitive impairment, was found unresponsive on the van due to prolonged heat exposure. The facility's lack of preparation and coordination during the emergency closure placed residents at risk of physical and emotional harm, hospitalization, and death.
Failure to Notify Residents and Ombudsman of Transfer or Discharge
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the State Long-Term Care Ombudsman regarding the transfer or discharge of residents. Specifically, the facility did not send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Ombudsman for two residents reviewed for transfer and discharge. This lack of communication could affect residents by placing them at risk of being discharged without proper advocacy services, discharge options, and appeal processes. Resident #12, a male with multiple health issues including hepatic encephalopathy and chronic kidney disease, was informed by his responsible party (RP) that the facility was closing the next day. The RP stated that no staff offered assistance in finding a new place, and she had to arrange for an apartment for the resident herself. Similarly, Resident #1, a male with severe cognitive impairment and paraplegia, was not notified by the facility about his transfer. His RP learned about the move from another family member and had to leave work to assist with the transfer. The Director of Nursing (DON) was out of town and unable to provide facility policies when requested by the surveyor. The DON expressed concerns about staffing shortages and stated that the facility had not notified families about the closure. The facility's owner confirmed an emergency temporary closure due to staffing issues, but residents were only notified the day before the closure. The Ombudsman was also unaware of the facility's closure, highlighting a significant communication breakdown.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to a deficiency in meeting the residents' discharge goals and needs. Resident #1, a male with severe cognitive impairment and multiple health issues, was not provided with a discharge plan. His responsible party was not informed about his transfer to another facility, causing distress and lack of preparation for the family. The facility did not give the family enough time or options to find a suitable place closer to them. Similarly, Resident #12, a male with significant health conditions, was also affected by the facility's inadequate discharge planning. The responsible party for Resident #12 was informed only a day before the facility's closure, leaving them to arrange alternative accommodation without assistance from the facility. The facility staff were unaware of the closure plans, and no help was offered to the resident or their family in finding a new place. The Director of Nursing (DON) was out of town and unable to provide the facility's policies when requested by the surveyor. The DON expressed concerns about staffing shortages and was not informed about the residents' transfers until shortly before they were scheduled. The facility's policy on transfer and discharge was not followed, as there was no documentation of resident or representative notice, comprehensive care plans, or communication with receiving facilities. The physician for the residents was also unaware of the transfers and expressed concerns about the facility's administration and staffing issues.
Insufficient Staffing Leads to Facility Closure
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, compromising their safety and well-being. This deficiency was identified through observations, interviews, and record reviews. The owner acknowledged the staffing issue, which had persisted for approximately 1.5 weeks, and despite efforts to contact agency staffing, use staff from a sister facility, and hire a recruiter, the facility was unable to secure adequate staffing. This lack of staffing was cited as the primary reason for the decision to close the facility. During the investigation, it was noted that a registered nurse was unable to leave her shift due to the absence of a relieving nurse, indicating a severe shortage of nursing staff. Additionally, a bus driver, who was not a certified CNA, was responsible for transporting 13 residents to a sister facility without any accompanying nursing or CNA staff. This situation highlighted the facility's failure to adhere to its staffing policy, which mandates adequate staffing to meet resident care needs, including the presence of licensed nursing staff and CNAs on each shift.
Failure to Administer Medications During Resident Transport
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, resulting in them not receiving their prescribed evening medications. Resident #1, a male with severe cognitive impairment and multiple health conditions, was admitted to the hospital after experiencing syncope and suspected seizures. His Medication Administration Record (MAR) indicated he was due for an evening dose of Divalproex Sodium, which he did not receive due to the facility's failure to administer it. Resident #13, who had moderately impaired cognition and required total assistance with most activities of daily living (ADLs), was also affected. He was being transported to a new facility when the van broke down, and he did not receive his evening medications, including antibiotics, anxiety, and opioid medications. This lapse occurred because there was no nursing staff present during the transport to administer medications or provide care. Similarly, Resident #14, with moderately impaired cognition and various health issues, did not receive his evening medications while being transported to a new facility. The facility's policy on medication administration was not followed, as medications were not administered within the required time frame, and there was no staff to ensure medication administration during the transport. This oversight placed the residents at risk of not receiving the intended therapeutic benefits of their medications.
Failure to Provide Adequate Meals During Resident Transfer
Penalty
Summary
The facility failed to provide at least three meals daily at regular times or in accordance with resident needs for two residents, Resident #5 and Resident #6, during their transfer to another facility. On 08/07/24, both residents were being transferred at 6:00 p.m. and did not receive a normal evening meal. Instead, they were given half a sandwich to take on the van. This action was due to an emergency temporary closure of the facility caused by staffing concerns, as revealed by the owner. Resident #5, a male with schizoaffective disorder, schizophrenia, cognitive communication deficit, and generalized anxiety disorder, was on a mechanical soft diet due to being edentulous. His care plan aimed to maintain adequate nutritional status. Resident #6, a male with multiple health conditions including diabetes mellitus and being edentulous, also had a care plan goal to maintain adequate nutritional status. Both residents were moderately cognitively impaired, as indicated by their BIMS assessment scores. During the transfer, the facility did not provide any nursing staff on the van to administer medications or provide care if needed. The van broke down, leaving the residents stranded for several hours without adequate food. Resident #5 expressed hunger and was observed buying snacks from a vending machine at a rest station. The facility's emergency disaster policy, which was presented instead of a dietary policy, outlined a 3-day menu for emergencies but did not address the specific needs of residents during the transfer.
Facility Mismanagement and Lack of Licensed Administrator
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently, impacting the well-being of its residents. The facility was without a licensed Administrator for approximately 1.5 weeks, as the previous Administrator had resigned due to financial mismanagement and unpaid bills. The Owner, who was not licensed in Texas, was aware of the staffing issues and had attempted to address them by contacting agencies and using staff from a sister facility. However, the Owner did not hire a new Administrator or notify state licensing authorities about the facility's closure plans, citing a lack of knowledge on how to contact them. The Director of Nursing (DON) and the former Administrator reported significant operational issues, including unpaid vendors leading to a lack of essential services such as pest control, HVAC maintenance, and dietary supplies. The DON began notifying residents and families of a potential closure despite the lack of formal communication from the Owner. The Medical Director also reported not being paid for over six months but continued to provide care. These issues were compounded by the Owner's failure to follow proper procedures for emergency closure and resident transfer, contributing to the facility's decline and the deficiency noted in the report.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure that it had a licensed Administrator responsible for its management, as required by state regulations. The Owner, who was acting as the Administrator, did not possess an active Texas Administrator license. The facility had been without a licensed Administrator for approximately 1.5 weeks after the previous Administrator quit without notice. The Owner, who was licensed in another state, did not actively seek a replacement Administrator and did not notify the Health and Human Services Commission (HHSC) about the absence of a licensed Administrator. Interviews conducted with the Owner and the Director of Nursing (DON) revealed that the facility was planning to close, and residents were to be transferred to a sister facility. The DON assumed the role of the designated Abuse Coordinator in the absence of an Administrator. A review of the facility's records confirmed the employment and termination dates of the former Administrator, who had worked at the facility for a brief period before resigning. The governing body list indicated that the Owner was the sole contact, highlighting the lack of a structured management team.
Failure to Provide Timely Closure Notification
Penalty
Summary
The facility failed to provide written notification of an impending closure to residents and their legal representatives at least 60 days prior to the closure date, affecting three residents reviewed for discharge notice. This failure was identified through interviews and record reviews, revealing that residents and their representatives were not informed in a timely manner, which could impact their access to advocacy services, continuity of care, and appropriate discharge options. The facility's Emergency Nursing Home Closure Policy was not followed, as it required immediate notification to regulatory authorities and written notice to residents and families ideally within 24 hours. Resident #1, a male with severe cognitive impairment and multiple medical diagnoses, was visibly upset about the move and expressed a desire to stay near family. His representative was informed only a day before the planned transfer and received no assistance from the facility in finding a new placement. Similarly, Resident #8, with schizoaffective disorder and other conditions, learned about the closure from another resident and informed his representative, who also received no guidance from the facility. Resident #12's representative was informed by an aide and decided to take the resident home, arranging hospice care independently. The facility's lack of communication and support in these cases highlights the deficiency in adhering to closure notification requirements.
Failure to Notify and Plan for Facility Closure
Penalty
Summary
The facility failed to have policies and procedures in place that outline the duties of the Administrator in the event of a facility closure. This deficiency was identified through interviews and record reviews, revealing that the facility did not notify the State Survey Agency, the State Long-Term Care Ombudsman, residents, their legal representatives, or the facility Medical Director about the closure. The facility's operation was being conducted by the Owner, who did not hold a state Administrator license, and there was no Licensed Administrator since 7/26/24. Interviews with the Director of Nursing (DON) and the Ombudsman indicated that the decision to close the facility was made abruptly, with the Owner informing the staff on 8/5/24 and deciding on 8/6/24 that the facility would close the next day. Residents were to be moved to a sister facility 2.5 hours away without prior notice to residents, families, or state agencies. The DON confirmed that there was no closure plan in place, and the process was improvised. Residents and their representatives were informed of the closure through informal channels, such as other residents or aides, rather than official communication from the facility. Some residents' representatives had to make their own arrangements for relocation, as the facility did not provide assistance or a list of alternative placements. The facility Medical Director was also unaware of the closure until informed by the DON on the day of the closure.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents who authorized the facility to manage their personal funds had access to those funds when requested. This deficiency affected two residents, both diagnosed with schizoaffective disorder and other medical conditions, who experienced delays in receiving their personal funds. Resident #4 reported being unable to access her money as scheduled, which caused stress and prevented her from purchasing essential items. She was informed that the Business Office Manager (BOM) had quit, leaving no one to disburse the funds, resulting in a delay of over two weeks before she received her money. Similarly, Resident #5 experienced a delay of about 17 days in receiving his monthly personal funds, which he depended on for his financial needs. He expressed dissatisfaction with the situation, as it hindered his ability to manage his financial affairs timely. The former Administrator confirmed that the BOM had quit and that the facility was experiencing financial difficulties, which affected the disbursement of residents' funds. The facility's policy on resident trust accounts was not adhered to, as the monitoring systems failed to ensure funds were handled according to state regulations.
Deficiencies in Food Service Safety and Supply Management
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. A dietary aide was found not wearing a hair net while in the kitchen, which is a basic requirement for maintaining hygiene. Additionally, the exhaust vent filters of the range hood were observed to be dirty, with a sticky, brown-colored substance identified as grease, indicating a lack of regular cleaning. The facility also failed to properly label and dispose of leftovers in the refrigerator, with several containers of food found unlabeled. Furthermore, the facility did not maintain the required 7 days of staple supplies and 2 days of perishable foods for emergencies, and was not following a set menu, which could lead to food contamination and foodborne illness. Interviews with staff revealed financial difficulties impacting the facility's ability to procure food supplies. The Dietary Manager (DM) reported that food orders were being cut due to unpaid bills, and she was limited to spending $1000 per week, forcing her to make daily trips to a local grocery store for supplies. The DM confirmed the lack of emergency supplies and the absence of a set menu, with meals being improvised daily. The Director of Nursing (DON) acknowledged the financial struggles and the use of local stores for supplies, but noted that residents' weights were maintained and there were no complaints about the dietary services. A resident mentioned that while the food was good, they were unaware of the menu until mealtime.
Failure to Maintain Licensed Administrator and Notify HHSC
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and regulations by not having a licensed nursing facility administrator in place. The deficiency occurred when the facility's administrator quit without notice, and the owner, who is not licensed in Texas, did not immediately notify Health and Human Services (HHSC) of the vacancy. The owner, who is the only governing body contact, did not actively seek a new administrator and decided to close the facility, transferring residents to a sister facility. The former administrator cited unpaid bills as the reason for leaving, having raised concerns with the owner, who responded that there was no money available.
Latest citations in Texas
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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