Villa Toscana At Cypress Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 15015 Cypress Woods Medical Dr, Houston, Texas 77014
- CMS Provider Number
- 676239
- Inspections on file
- 35
- Latest survey
- May 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Villa Toscana At Cypress Woods during CMS and state inspections, most recent first.
Hand hygiene was not performed consistently during breakfast tray service in the secured unit. A CNA did not wash or sanitize hands before serving residents or between trays, and an LVN did not wash or sanitize after assisting a resident and completing an assessment before bringing the resident to the dining room, removing gloves, receiving a breakfast plate, and starting to feed the resident. The DON stated staff are expected to sanitize hands before and after handling trays and that gloves are not a substitute for handwashing.
Failure to Update Care Plan for High Elopement Risk: A resident with dementia, poor memory and decision-making, and wheelchair mobility had repeated high-risk elopement assessments showing she could propel herself, required cues/supervision, and had recent exit-seeking behavior. After she was found outside the building and redirected back inside, the care plan did not reflect the earlier high-risk elopement findings, and the documented interventions focused mainly on wandering or activity participation rather than the assessed elopement risk.
Multiple cognitively impaired and medically complex residents were not consistently offered adequate fluids or provided with accessible water at the bedside, despite care plans identifying potential fluid deficits and a facility policy requiring regular hydration offerings. Observations on multiple days found residents in bed or in wheelchairs without water or other fluids within reach, with some receiving only small 4–8 oz portions of juice or milk on meal trays and no additional water. Staff described confusion over who was responsible for filling ice chests, reported that fresh water was not passed on certain halls for two days, and noted that meal trays did not routinely include water. The LD and MD stated residents should be offered at least 1500–1900 cc of fluids daily, while documented meal offerings were below this amount, and the DON and ADON acknowledged that expected hydration rounds and ice water service each shift were not carried out as observed.
A resident with severe cognitive impairment, multiple complex medical conditions, and contracted hands was care planned to use the call light for assistance and fall prevention, with staff directed to keep it within reach and encourage its use. Despite this, the resident was repeatedly observed yelling for help from his room while a standard call button, difficult for him to operate due to his hand contractures, was within reach. The resident reported that using the standard call button required extreme effort, and CNAs reported he could not effectively use it and requested a flat call button to accommodate his needs, but subsequent observations showed he still had only the standard device. This resulted in a failure to reasonably accommodate the resident’s needs for an accessible call system as required by the facility’s resident rights policy.
A resident with severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for toileting hygiene was not checked or provided incontinence care for approximately six hours during the day, despite a care plan directing checks every two hours and frequent incontinence care. Observations showed the resident in common areas for much of the day in the same clothing, and the resident reported her brief had not been changed since getting out of bed. Electronic surveillance indicated no return to the room for care during this period, and incontinence care was documented only in the early morning and late evening. Staff interviews and facility policy confirmed that residents should be checked and changed every two to three hours, but this did not occur for this resident.
A nurse left a computer screen displaying a resident's confidential health information open and unattended on a locked nursing cart, making the information visible to unauthorized individuals. The resident involved had multiple medical conditions and moderate cognitive impairment. Staff acknowledged responsibility for securing information and confirmed receipt of HIPAA training, but the incident revealed a lapse in following established privacy protocols.
Three residents were found with bed rails in use without physician orders or documented assessments for medical necessity. Staff interviews revealed inconsistent understanding of restraint policies, with some staff unaware that bed rails could be considered restraints or that a doctor's order was required. Facility policy required assessment and informed consent prior to bed rail use, but these procedures were not followed, and multiple residents had bed rails in use without proper evaluation.
Two residents with severe cognitive impairment were found to have untrimmed, thick, and abnormally curved toenails, with one resident experiencing pain and difficulty wearing shoes. Despite care plans and facility policy requiring regular nail care, staff interviews revealed confusion about responsibility and a lack of follow-through, resulting in untreated abnormal nail conditions.
A resident did not receive ordered medications after an RN signed for a pharmacy delivery without verifying its contents, and the medications could not be located when needed. Interviews with LVNs and the DON revealed inconsistent practices in medication cart audits and verification of received medications, with loose pills found in medication carts and staff admitting to not always checking deliveries. Facility policy required proper storage and verification, but these procedures were not followed, resulting in the deficiency.
During a medication cart audit, two unidentifiable loose pills were found at the bottom of a drawer, with staff interviews revealing inconsistent practices in medication cart audits and verification of received medications. The DON acknowledged training on medication storage but was unclear on specific policies regarding loose pills, and the facility's policy requires immediate removal of such medications. This resulted in a failure to ensure all drugs and biologicals were stored and labeled according to professional standards.
The facility's medication error rate was 18.52%, exceeding the acceptable threshold of 5%. Errors included unavailability and incorrect administration of medications for three residents. Staff interviews revealed lapses in ensuring medication availability and correct administration, contributing to the high error rate.
The facility failed to label Latanoprost eye drops with expiration dates for five residents, as observed during a review of medication carts. Staff interviews revealed a lack of adherence to the facility's medication storage policy, which requires dating medications when opened. This oversight could lead to residents receiving expired medications, potentially affecting their therapeutic effectiveness.
The facility failed to properly label and date leftover food items in the walk-in cooler and stored expired food products in the pantry, risking food-borne illnesses. The Dietary Manager acknowledged the oversight, and the Corporate Dietitian confirmed the interchangeable use of 'used by' and 'best by' dates in company policy.
A resident with Alzheimer's and severe cognitive impairment was admitted to a facility but did not receive her prescribed medications on the day of admission. Despite having systems to obtain medications from an emergency kit or automated dispensing system, the medications were not administered, and staff could not explain the oversight. The facility's policy required medications to be administered at the first scheduled time after arrival, which was not followed.
Multiple residents with cognitive and physical impairments were subjected to abuse by another resident with a history of behavioral issues, despite a care plan requiring 1:1 supervision. The resident in question slapped two other residents on the same day, and staff interviews and documentation revealed confusion and lapses in the implementation of required supervision, resulting in residents being placed at risk of harm.
A medication aide was observed eating on the med cart, failing to sanitize hands, equipment, and the cart before and during medication administration for three residents with complex medical needs. The aide did not follow hand hygiene protocols, did not sanitize the blood pressure cuff between uses, and handled medications and equipment after touching potentially contaminated surfaces, contrary to facility policy.
A resident with hemiplegia and hemiparesis was found without a call light within reach, leading to a delay in care as she was left saturated with urine. The facility's call light system was not functioning, and staff failed to ensure the manual bell was accessible, despite being trained to conduct 15-minute checks. This oversight placed the resident at risk of not receiving timely assistance.
A resident in an LTC facility did not receive timely incontinent care due to staff inaction and a non-functioning call light system. The resident, who required assistance with ADLs, was found soaked in urine, expressing discomfort and frustration. Staff interviews revealed a lack of adherence to the protocol of checking on residents every 15 minutes, contributing to the delay in care.
A resident with multiple medical conditions, including cognitive deficits and osteoporosis, fell from bed and fractured her femur due to inadequate supervision. A CNA mistakenly believed the resident required only one-person assistance, contrary to the care plan that specified two-person assistance for bed mobility. This oversight led to the resident rolling off the bed during incontinence care, resulting in a serious injury.
A resident with dementia and other health issues developed a rash, but the LTC facility failed to notify the physician promptly. Despite ongoing itching and scratching, the rash was not communicated to the physician or family, as indicated in weekly skin assessments. The facility's policy required immediate notification of significant changes, but this was not followed, delaying medical intervention.
A resident with dementia and other health issues developed an unexplained rash due to the facility's failure to conduct timely skin assessments. Despite a history of skin problems, the resident's condition was not documented or communicated to the physician, leading to a delay in care. Staff interviews revealed a lack of awareness and communication regarding the resident's condition, and the facility lacked a clear protocol for reporting changes in skin condition.
Two residents with dementia eloped from a memory care unit due to inadequate supervision and unsecured doors. The facility failed to ensure proper monitoring and response to door alarms, allowing the residents to exit the unit. Staff interviews revealed inconsistencies in monitoring procedures and security measures, contributing to the elopements.
Hand Hygiene Not Performed During Breakfast Tray Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 2 of 4 staff members reviewed for food service safety. During an observation in the secured unit at breakfast, CNA B did not wash or sanitize hands before serving a resident's breakfast, between serving consecutive residents, or while moving back and forth between residents and meal trays. At 9:41 a.m., LVN A did not wash or sanitize her hands after assisting a resident and completing an assessment. LVN A then brought the resident to the dining room, removed her gloves, received the resident's breakfast plate, and immediately began assisting with feeding. There were 8 residents in the secured unit dining room during breakfast. In interviews, LVN A stated she washes her hands before handling trays and afterward, but was unsure where she was required to sanitize between trays. CNA B stated that staff are supposed to wash or sanitize hands between passing trays, but she did not do so because she was rushing to ensure residents received breakfast before the food got cold. The DON stated the expectation was to sanitize hands before receiving a tray, after placing it down, and before touching another tray, and that gloves are not a substitute for handwashing.
Failure to Update Care Plan for High Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia, cerebrovascular disease, seizures, anxiety, depression, difficulty walking, dysphagia, and cognitive communication deficit. The resident’s quarterly MDS showed a BIMS score of 4 out of 15, indicating significant difficulty with memory, decision-making, and understanding surroundings, and she used a wheelchair for mobility with partial/moderate assistance for transfers and walking-related tasks. An elopement risk assessment completed by the ADON showed a score of 23, indicating high risk for elopement, and later assessments completed by the DON also showed high-risk scores of 27. The assessments documented that the resident could propel herself, had poor decision-making, required cues/supervision, had attempted to leave the facility in the past week, did not recognize stop lights or street-crossing precautions, and knew the location of her current residence. After the resident exited the building and was redirected back inside, the care plan was not updated to reflect the elopement risk findings from the high-risk assessment. The resident’s care plan initiated on 04/14/2026 included a focus for an actual elopement or elopement attempt and listed interventions related to wandering, repeated requests to leave, and staying with the resident if exit-seeking. However, the care plan did not include any focus or interventions from the earlier high-risk elopement assessment dated 10/31/2025. A later care plan entry on 04/29/2026 addressed the resident’s recent transition to the secure unit and possible confusion and social isolation, with activity-based interventions, but it did not reflect the elopement risk assessment findings that identified the resident as high risk for elopement.
Failure to Consistently Offer and Maintain Accessible Hydration for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multiple residents were consistently offered sufficient fluids and had fluids within reach, as required by their care plans and the facility’s hydration policy. Eight residents with severe cognitive impairment and various medical conditions, including renal disease, dementia, Parkinson’s disease, cerebrovascular disease, malnutrition, and mobility deficits, were observed on multiple occasions without accessible drinking water or other fluids at their bedsides or in their rooms. Care plans for these residents identified potential fluid deficits related to conditions such as dialysis, poor memory, low intake, memory loss, dementia, and ADL self-performance deficits, and included interventions such as encouraging fluids, ensuring fluids were within reach, and informing nursing staff if residents refused fluids. Meal tickets for these residents showed they were typically provided between 24 and 32 ounces of fluids per day on meal trays, often in small 4–8 ounce portions of juice or milk, with no additional water routinely present on the trays. On specific observation dates, surveyors repeatedly found residents in bed or in wheelchairs with no water or other fluids within reach, despite their dependence on staff for transfers and assistance with eating and drinking. One resident with end stage renal disease and dysphagia had a 32‑ounce cup of water placed on a windowsill out of reach and reported the water was not fresh and that he did not know when it had last been refilled; at another meal he drank the only 8‑ounce drink on his tray and stated he would drink more if more were available. Other residents were observed waiting for breakfast or asleep in bed with no water at the bedside, and in some cases the only fluids present during meals were small cups of juice and milk. Several residents were unable to independently access fluids placed on shelves or other surfaces out of reach, and some expressed thirst or a desire for water when asked. Staff interviews and environmental observations further described systemic issues with the hydration process. An ice chest on one hall was observed with only an inch of water and a few ice cubes early in the morning, and later the same day it still contained only an inch of water with the ice melted or removed. A CNA reported uncertainty about who was responsible for filling the ice chest, stated that on two days no one filled it and fresh water was not passed on certain halls, and noted that residents who could not get up had to ask for water. The CNA also stated that the cups on meal trays were small and that trays did not routinely include water. The licensed dietitian stated that residents should be offered about 64 ounces of fluid daily, with a minimum of 50 ounces even for those with fluid restrictions, and acknowledged that if residents received only small amounts at meals, nursing would need to consistently offer additional fluids. The ADON and DON both stated that fresh ice water was expected to be passed every shift and that ice chests and scoops were to be maintained, but acknowledged that for at least two days nursing staff had not ensured residents received fresh ice water and that meal trays did not include water. The facility’s hydration policy required staff to offer hydration during direct care interactions, around meals, during medication passes, and during activities, and to maintain fresh water at the bedside when not contraindicated, but observations and interviews showed these practices were not consistently followed for the residents reviewed. Additional interviews with nursing staff and administration confirmed that there was no clearly assigned responsibility for filling and cleaning the ice chests each shift, and that the ice machine on one side of the building was broken, requiring staff to go to the other side for ice. A CNA reported that aides were supposed to fill pitchers with water every two hours when the ice chest was filled, but that they waited for someone to fill the chest and, during the two days in question, this did not occur. The ADON and DON both stated that residents were also receiving fluids through medication administration and beverages such as juice, milk, and coffee at and between meals, but acknowledged that ice water needed to be offered every shift and that the observations made during the survey were not consistent with their expectations. The medical director and licensed dietitian both indicated that residents should be offered at least 1500–1900 cc (50–64 ounces) of fluids daily, while the documented meal offerings for the affected residents fell below this minimum, and the lack of consistent bedside water and hydration rounds contributed to residents not being offered the minimum quantity of fluids on the days observed.
Failure to Provide Accessible Call Light for Resident With Contracted Hands
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences regarding use of the call light system. The resident was an older male with multiple diagnoses including end stage renal disease, altered mental status, bipolar disorder, metabolic encephalopathy, thrombocytopenia, congestive heart failure, restlessness and agitation, dysphagia, muscle weakness, abnormal posture, and cognitive communication deficit. His admission MDS showed a BIMS score of 06, indicating severe cognitive impairment, and documented no limitations in upper extremity range of motion. His care plan identified an ADL self-care performance deficit and risk for falls, with interventions directing staff to ensure the call light was within reach and to encourage him to use it for assistance. On multiple observations, the resident was heard repeatedly yelling “Nurse! Nurse!” from his room instead of using the call button. During one observation, the ADON responded after the second episode of yelling and found the resident with a standard call button within reach. Both of his hands were contracted. In a subsequent interview and observation, the resident stated he knew how to press the call button but had great difficulty doing so because of his hands. He demonstrated that he could pick up the call button with his right hand and use a finger on his left hand to press it, but this required extreme effort and concentration. Additional observations showed the resident continuing to yell for assistance, with staff responding to his calls from the hallway. Staff interviews confirmed that the resident was unable to effectively use the standard call button due to his contracted hands. A CNA who regularly worked on the resident’s hall stated that he could not use the call button and that she and another aide had notified the nurse on the hall that he needed a flat call button to accommodate his condition. Another observation documented a CNA asking an LVN to obtain a flat call button so the resident could more easily use it and stop yelling into the hall. However, a later observation showed that the resident still had the standard call button and no flat button, and he stated he would have liked and used a flat call button if he had one he could more easily press. The facility’s Resident Rights policy stated that residents have the right to reside and receive services with reasonable accommodation of their needs and preferences, which was not implemented for this resident’s call light needs.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically toileting hygiene and incontinence care, to a cognitively impaired resident who was fully dependent on staff for these needs. The resident was an elderly female with diagnoses including cerebral infarction, cognitive communication deficit, lack of coordination, overactive bladder, and dementia, and her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment. Her care plan documented bowel and bladder incontinence, with goals to prevent complications and maintain function, and interventions that included checking her every two hours, assisting with toileting as needed, and providing frequent incontinence care with moisture barrier application. On the date in question, documentation of toileting hygiene and incontinence care tasks reflected that the resident received incontinence care at 12:17 AM and again at 8:56 PM, with no care recorded for the day shift between 6 AM and 2 PM. Observations showed the resident seated in the living room eating breakfast at 9:15 AM and later participating in activities and receiving lunch, remaining in the same clothing throughout the morning and early afternoon. During an interview in the late morning, the resident stated that her brief had not been changed since she got out of bed, though she could not specify the time. Review of automated electronic surveillance video for that day showed that the resident’s room camera did not activate between 9:10 AM and 3:30 PM, with activation only when she was brought back to her room and provided incontinence care at 3:30 PM. The family member reported monitoring the video and stated they did not see the resident return to her room for incontinence care until that time, and that they had to call the nurse’s station to request care. Facility staff, including an RN, a CNA, the DON, and the ADM, all stated that residents should be checked and changed every two to three hours, and the facility’s perineal care policy required incontinent residents to be checked and changed as needed based on an appropriate schedule. Despite these expectations and policies, the resident was not checked or provided incontinence care for approximately six hours during the day.
Failure to Secure Resident Health Information on Unattended Computer Screen
Penalty
Summary
A deficiency occurred when a nurse left a computer screen displaying a resident's personal health information open and unattended on a locked nursing cart in a hallway. The computer was left visible for several minutes, during which time anyone passing by, including visitors or other residents, could have seen the confidential information. The nurse acknowledged receiving HIPAA training and stated she was responsible for closing the computer screen when stepping away. The Director of Nursing confirmed that facility policy requires screens to be minimized when not in use and that monitoring is conducted through observation rounds. The resident whose information was exposed was a 55-year-old male with multiple medical conditions, including intestinal obstruction, colon cancer, ileostomy status, essential hypertension, and mild intellectual disabilities, with a BIMS score indicating moderate cognitive impairment. Facility records confirmed that staff receive HIPAA training at hire and annually, and that policies require locking or logging off devices when unattended. However, documentation showed that in-service training on cart protocol was only recently provided, with no earlier records available for review.
Failure to Assess and Document Medical Need for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper evaluation for medical necessity. Three residents were observed with both side bed rails raised on their beds, yet none had physician orders or documented assessments justifying the use of bed rails. Interviews with residents and their representatives revealed that the bed rails were not requested by the residents and were instead implemented by staff, often as a measure to prevent falls. One resident was observed attempting to get out of bed while the bed rails were up, indicating a lack of individualized assessment for their use. Staff interviews demonstrated inconsistent understanding and application of restraint policies. Some staff members believed that bed rails did not require a physician's order and did not consider them restraints, while others stated that an order and assessment were necessary. The Director of Nursing acknowledged that the facility aimed to be restraint-free but admitted that bed rails were used for mobility assistance and to prevent falls, despite some incidents of bruises and skin tears associated with their use. There was no evidence that residents had been properly assessed for the risks and benefits of bed rail use, nor that informed consent had been obtained prior to installation. Facility policy required assessment for risk of entrapment, review of risks and benefits, and informed consent before bed rails were used, but these steps were not documented or followed for the residents in question. Observations confirmed that bed rails were in use for multiple residents during the survey, and staff interviews further highlighted a lack of training and awareness regarding restraint policies and the potential for bed rails to be considered restraints.
Failure to Provide Regular Toenail Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, resulting in untrimmed, thick, and abnormally curved toenails. Observations revealed that both residents had toenails approximately one inch long, yellowish, thick, and in some cases, digging into the skin. One resident reported pain and an inability to wear shoes due to the condition of her toenails. Both residents were noted to have severe cognitive impairment and required assistance with personal care, including dressing and footwear. Record reviews indicated that both residents had care plans identifying self-care deficits and interventions for nail care, such as checking and trimming nails during bathing. However, interviews with staff, including CNAs, the DON, and the social worker, revealed a lack of clarity and follow-through regarding responsibility for toenail care. Staff stated that a podiatrist visited the facility every 62 to 90 days and that non-diabetic residents should receive toenail care from facility staff during showers. Despite these policies, staff were unaware of why the residents' toenails had not been trimmed or referred to the podiatrist. The facility's ADL Nail Care Policy required regular and safe nail management to promote cleanliness and prevent infection or injury. Despite this policy, both residents were observed with abnormal nail conditions, and staff interviews confirmed that expected nail care was not provided. The lack of toenail care was not explained by staff, and the residents remained with untreated, overgrown toenails at the time of the survey.
Failure to Verify and Account for Delivered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident by not ensuring that medications delivered from the pharmacy were properly checked and accounted for before being signed off by nursing staff. Specifically, an RN signed for a medication delivery without verifying the contents of the package, and the medication could not be located when needed. The Director of Nursing (DON) confirmed that the nurse did not confirm what was in the bag and could not recall who opened the package. The hospice nurse later requested the medication, but it was missing, and the facility was unable to determine its whereabouts. Interviews with several LVNs revealed inconsistent practices regarding the verification and auditing of medication carts (MCs) and the handling of loose medications. LVNs reported that audits of the MCs should be done daily, but loose medications were found at the bottom of the carts, which could indicate that residents did not receive their medications as prescribed. One LVN admitted to never verifying medications sent from the pharmacy, and another described the process for handling controlled medications but did not mention verification of non-controlled medications. The DON and ADM both acknowledged that staff are responsible for verifying and signing off on medications upon receipt, and that failure to do so could result in residents not receiving their medications. Record review showed that the RN who signed for the medication delivery documented receiving specific medications and storing them in the narcotic lock box, but the medications were not found when needed. The facility's policy required medications to be stored safely and securely, with outdated or compromised medications removed immediately. Despite these policies, the lack of proper verification and storage led to the deficiency, as medications were not properly tracked or accounted for, resulting in the potential for residents to miss doses.
Loose, Unidentifiable Medications Found in Medication Cart
Penalty
Summary
A deficiency was identified when an audit and observation of medication cart #1 revealed two unidentifiable loose pills at the bottom of a drawer, under blister packs. Multiple interviews with LVNs confirmed that daily audits of medication carts are expected, but loose medications can occur when pills are accidentally dropped during administration. Staff acknowledged that such occurrences could result in medications not being administered as prescribed. One LVN described the loose pills as potentially an antipsychotic and melatonin. Another LVN stated that she had never verified medications received from the pharmacy, and described the process for handling controlled and reordered medications, indicating inconsistencies in medication management practices. The Director of Nursing (DON) confirmed that training on medication storage had been provided, but could not recall the last time she received it and was unsure of the specific policy regarding loose medications in carts. The DON and other staff stated that both the ADON and the pharmacist are responsible for monitoring medication carts through regular checks. The facility's policy requires that medications be stored safely, securely, and properly, and that any outdated, contaminated, or unidentifiable medications be immediately removed. Despite these policies, the presence of loose, unidentifiable pills in the medication cart indicated a failure to adhere to proper medication storage and labeling protocols.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 18.52%. This was based on 5 errors out of 27 opportunities, involving three residents. The errors included the unavailability and incorrect administration of medications. Specifically, Resident #26 did not receive Ferrous Sulfate and Calcium-Vitamin D as ordered, and Resident #37 did not receive Glucosamine HCL 500 mg as prescribed. Additionally, Resident #77 was administered the wrong dosage of Fish Oil and an incorrect formulation of a B-Complex vitamin. The observations revealed that the medications for Residents #26 and #37 were not available on the medication cart at the time of administration. Medication Aide G was unable to find the correct dosages and notified the nurse, but the medications were held instead of being administered. For Resident #77, the wrong dosage of Fish Oil and an incorrect B-Complex vitamin were administered, as confirmed by Medication Aide H during an interview. Interviews with staff, including the Director of Nursing (DON) and Assistant Directors of Nursing (ADONs), highlighted that the facility's process for ensuring medication availability and correct administration was not followed. The DON and ADONs acknowledged that they typically check medication orders to ensure they match the facility's stock and contact doctors for updates if needed. However, the failure to have the correct medications available and administered as ordered led to the observed medication errors.
Failure to Label Latanoprost Eye Drops with Expiration Dates
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used in the facility were labeled with expiration dates when applicable, specifically for Latanoprost eye drops used by five residents. During observations, it was noted that the Latanoprost eye drops for Residents #20, #81, #35, #2, and #299 were not labeled with an open or expiration date. This oversight was identified during a review of the medication carts in the facility, where it was found that the eye drops were either not labeled with an open date or were being stored at room temperature without proper labeling. Interviews with facility staff, including medication aides and nursing staff, revealed a lack of adherence to the facility's policy on medication storage. Staff members acknowledged that eye drops should be dated when opened to ensure they are not used past their expiration date. The Director of Nursing (DON) and other nursing staff admitted to not knowing the policy by memory and recognized the potential for reduced effectiveness of medications if expired eye drops were administered to residents. The facility's policy on medication storage, which was reviewed, clearly states that medications requiring an open date should be labeled accordingly. The specific instructions for Latanoprost eye drops indicate that they should be refrigerated until initial use and expire 42 days after being stored at room temperature. The failure to label these medications properly could lead to residents not receiving the intended therapeutic effects or experiencing harmful side effects from expired medications.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, the facility did not label and date leftover food items in the walk-in cooler, and expired food products were found stored in the food pantry. These practices could potentially expose residents to food-borne illnesses and food contamination. During an observation and interview with the Dietary Manager, it was noted that the cooler contained expired food products, including sour cream, cottage cheese, and pimento cheese, all past their best-by dates. Additionally, the dry goods storage area contained expired items such as high-calorie protein supplements, chipotle containers, and imitation coconut extract. The Dietary Manager acknowledged that all food items removed from their original containers should be labeled and dated, and while dairy products past their best-by dates could still be used, they should not be used if they smelled bad. The facility's Corporate Dietitian confirmed that the terms 'used by' and 'best by' were used interchangeably in the company's policy, allowing the Dietary Manager to determine their application. The facility's policy emphasized maintaining storage areas in an orderly manner to preserve food condition, requiring open packages to be stored in sealed and dated containers.
Failure to Administer Medications Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident #300, upon her admission. Resident #300, a female with severe cognitive impairment due to Alzheimer's Disease and Vascular Dementia, was admitted to the facility with a requirement for specific medications to manage her conditions, including anxiety and depression. However, on the day of her admission, she did not receive her prescribed medications, which included Buspirone, Mirtazapine, and Depakote, as documented in her March Medication Administration Record (MAR). The failure to administer these medications was noted in the doctor's progress notes the following day. Interviews with facility staff, including the Director of Nursing (DON) and administrators, revealed that the charge nurse was responsible for ensuring medication administration, and there were systems in place to obtain medications from an emergency kit or automated dispensing system if needed. Despite these systems, the medications were not administered, and the DON could not provide an explanation for this oversight. The facility's policy on medication administration emphasized the importance of administering medications at the first scheduled time following a resident's arrival, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from abuse and did not ensure adequate supervision, particularly for a resident with a known history of behavioral issues. On the day in question, a resident with severe cognitive impairment and psychiatric diagnoses, who was care planned for 1:1 supervision due to a risk of physical behaviors, slapped another resident in the face. This incident was witnessed by staff and confirmed by resident statements and written accounts. The same resident was later involved in a second incident the same day, where she slapped another resident during a meal, despite being on 1:1 supervision at the time. Staff interviews and documentation revealed confusion and lack of clarity regarding who was responsible for the 1:1 supervision, with some staff unable to recall the incident or who was assigned to monitor the resident at critical times. The affected residents included individuals with significant cognitive and physical impairments, such as Alzheimer's disease, schizophrenia, anxiety, and muscle weakness. One resident was observed holding her face after being slapped, while another was unable to recall the incident but was assessed as calm and without injury. Staff assessments and interviews indicated that the residents involved were at their baseline following the incidents, but the events were distressing enough to prompt immediate staff intervention and notification of nursing and administrative leadership. Family members present during one of the incidents confirmed that staff were not in the room at the time of the abuse and only responded after being called for help. Documentation and interviews with staff, including CNAs, LPNs, the DON, and the Assistant Business Office Manager, revealed inconsistencies in the implementation and monitoring of the 1:1 supervision protocol. The monitoring chart showed gaps and changes in staff responsible for supervision, and some staff were unclear about their roles or unable to recall the events. The facility's policies required interventions and care planning to prevent further occurrences, but the lack of effective supervision and unclear staff responsibilities directly contributed to the residents being exposed to abuse and placed at risk of harm.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during medication administration for three residents. Medication aide (MA) A was observed eating food on the medication cart, with a blood pressure cuff and thermometer placed next to the food, and a cup of uncovered pudding on the cart. After eating, MA A did not sanitize his hands, the cart, or the blood pressure cuff before proceeding to administer medications. He also failed to wear gloves, wash hands, or use hand sanitizer between residents, and did not sanitize the blood pressure cuff between uses. During medication administration, MA A handled medications and equipment without proper hand hygiene, including crushing medications and brushing spilled medication off the cart onto the floor with his hand. He used a bed remote that had been on the floor to adjust residents' beds and continued to handle medications and equipment without changing gloves or sanitizing his hands. MA A also kept gloves on while retrieving items from his pocket and picking up objects from the floor, further compromising infection control. Interviews with MA A and the Director of Nursing (DON) confirmed that these actions were not in accordance with facility policy, which requires hand hygiene before and after eating, after contact with residents or equipment, and after removing gloves. The facility's policies also mandate that the medication cart and surrounding work area remain clean at all times. These failures were observed for residents with significant medical conditions, including chronic kidney disease, diabetes, dementia, encephalopathy, epilepsy, and hypertension.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of her needs, specifically regarding the accessibility of a call light. The resident, who was cognitively intact but required partial to moderate assistance with activities of daily living due to conditions such as hemiplegia and hemiparesis, was found without a call light within reach. During an observation, the resident expressed discomfort and frustration as she was unable to find her call bell and had been saturated with urine for over an hour without assistance. The call light system was not functioning, and the resident was given a manual bell, which was placed out of her reach on a bedside dresser. Staff interviews revealed a lack of adherence to the facility's protocol for ensuring call lights were within residents' reach, especially given the non-functioning call light system. CNA A, who was responsible for the resident's care, admitted to not checking if the call bell was accessible and had not entered the resident's room since the start of her shift. Other staff members, including LVNs and CNAs, also failed to ensure the call bell was within reach, despite being trained to conduct 15-minute checks due to the call light system outage. The facility's policy required that call signals and needed items be placed within residents' reach, and staff were responsible for ensuring this. However, multiple staff members, including the DON and Activities Director, acknowledged the oversight in not verifying the call bell's placement. This deficiency in care placed the resident at risk of not receiving timely assistance, as she was unable to call for help when needed.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required partial to moderate assistance with ADLs, was found to be soaking wet with urine, along with her bed sheets and temporary bed pad. The resident expressed discomfort and frustration, stating she had been saturated with urine for over an hour. The call light system was not functioning, and the resident's manual call bell was not within reach, which contributed to the delay in receiving care. Staff interviews revealed that the CNAs and nurses were responsible for checking on residents every 15 minutes due to the non-functioning call light system. However, the staff failed to adhere to this protocol. One CNA assumed another staff member had checked on the resident, while another CNA was focused on delivering breakfast trays and did not verify the resident's call bell was accessible. The LVN on duty also did not check the resident's condition during her rounds, only verifying the resident was in bed from the doorway. The Director of Nursing confirmed that staff were trained to ensure timely incontinent changes and that call bells should be within reach. The facility's policies on perineal care and resident rights emphasize the importance of providing comfort and ensuring call signals are accessible. The failure to provide timely care and maintain the resident's dignity and comfort was a direct result of staff inaction and lack of adherence to established protocols.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and provided adequate supervision to prevent accidents. This deficiency was identified when a CNA provided incontinence care to a resident who required assistance from two staff members, resulting in the resident rolling off the bed and sustaining a right femur fracture. The incident occurred because the CNA mistakenly believed the resident was a one-person assist and did not check the Kardex for the correct assistance level. The resident involved was an elderly female with multiple medical conditions, including cognitive communication deficit, muscle weakness, vascular dementia, osteoporosis, and Alzheimer's disease. She was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The resident's care plan indicated she was at risk for falls and required two staff members for bed mobility, which was not adhered to during the incident. Interviews with staff revealed a lack of awareness and understanding of the resident's care requirements, as some CNAs were unsure of the assistance level needed for the resident. The facility's policy on safe patient handling was not followed, as the CNA did not verify the resident's assistance needs in the Kardex, leading to the accident. This oversight placed the resident at risk for injury and required hospitalization for surgical intervention.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical condition. Specifically, the facility did not notify the physician when a resident developed a rash on her arms, legs, and back. This oversight was identified during a review of records and interviews, which revealed that the resident had been experiencing itching and scratching for some time, yet the physician was not informed in a timely manner. The resident, an eighty-five-year-old woman with dementia, anxiety disorder, malnutrition, and hypertension, had a history of skin issues. Despite this, the facility's records showed that the rash was not communicated to the physician or family, as indicated in the weekly skin assessments. The resident was receiving treatments such as Zyrtec and Eucerin cream for itching, but these were not new interventions, and the rash persisted without proper notification to the physician. Interviews with staff, including LVNs and the DON, revealed a lack of communication and documentation regarding the resident's condition. The DON was unaware of the rash until it was brought to her attention by the State Investigator. The facility's policy required immediate notification of the physician in case of significant changes, but this protocol was not followed, leading to a delay in appropriate medical intervention for the resident.
Failure to Conduct Timely Skin Assessments Leads to Rash Development
Penalty
Summary
The facility failed to conduct comprehensive and timely skin assessments for a resident, leading to the development of an unexplained rash. The resident, an eighty-five-year-old woman with dementia, anxiety disorder, malnutrition, and hypertension, was not given weekly skin assessments for two weeks. This lapse in care resulted in the resident developing a rash that was not promptly identified or treated, as evidenced by the lack of documentation and communication with the physician or family. The resident's medical records indicated that she had a history of skin issues, including a rash noted in previous assessments. Despite this, the facility did not maintain consistent skin assessments, and the rash was not reported to the physician or family. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, with some staff assuming the resident's itching and scratching were normal behaviors. The DON admitted to not having conducted any in-services on skin assessments or changes in condition since starting at the facility. The deficiency was further compounded by the absence of a clear protocol for reporting and documenting changes in skin condition. Staff interviews highlighted inconsistencies in performing and documenting skin assessments, with some staff unaware of the resident's rash until it was observed by the WCN and physician. The facility's failure to adhere to its own schedule for skin assessments and the lack of a policy on skin assessments contributed to the delay in addressing the resident's medical needs.
Elopement of Two Residents Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, resulting in the elopement of two residents from the memory care unit. Resident #4, who had a history of dementia and was at risk for elopement, managed to leave the facility on two separate occasions. On the first occasion, she was found outside the facility by a staff member from a nearby business. The facility's records indicated that the doors were not properly secured, which allowed her to exit. On the second occasion, Resident #4 was again found missing from the unit, indicating a lack of adequate supervision and monitoring. Resident #5, who also had a history of dementia and was identified as an elopement risk, managed to leave the facility on the same day as Resident #4's second elopement. The facility's investigation revealed that the residents were able to exit through unsecured doors, which were supposed to be locked and alarmed. The staff failed to adequately monitor the residents and respond to door alarms, which contributed to the residents' ability to leave the secure unit. Interviews with staff members, including CNAs and nurses, highlighted inconsistencies in the facility's procedures for monitoring residents and responding to door alarms. Staff members reported that they were expected to conduct rounds and headcounts, but there was no specific policy in place to ensure these were done consistently. Additionally, the facility's doors were found to disengage during power outages, further compromising the security of the memory care unit. These lapses in supervision and security measures led to the residents' elopements, posing a risk to their safety.
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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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