Wharton Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wharton, Texas.
- Location
- 1220 Sunny Lane, Wharton, Texas 77488
- CMS Provider Number
- 675361
- Inspections on file
- 34
- Latest survey
- April 19, 2026
- Citations (last 12 mo.)
- 5 (4 serious)
Citation history
Health deficiencies cited at Wharton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, prior septic shock, and a history of falls was on 72‑hour neuro checks after a fall with head injury when BP and HR dropped well below his established baseline, triggering first‑time use of PRN Midodrine ordered for SBP <90. An LVN administered the PRN Midodrine and documented it as effective, but there was no documented follow‑up assessment, no contemporaneous neuro‑check findings addressing the episode, and no notification to the provider despite the facility’s policy requiring consultation for significant changes in condition and new treatment. The next morning, staff observed new left‑sided facial droop, weakness, and inability to mouth words, EMS was called for possible stroke, and the resident was sent to the hospital, where he was found to be hypotensive and diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy.
A resident with dementia, COPD, prior septic shock, and a history of falls had been placed on neuro checks after a recent fall with head injury. Despite previously stable BPs and pulses, the resident developed hypotension (81/48) and bradycardia (HR 55), for which an LVN administered PRN Midodrine per order. After this administration, there was no contemporaneous documentation of further assessment or monitoring of the resident’s condition, and neuro assessment entries for that day were signed late. The care plan did not address hypotension or bradycardia, the episode was not treated as a change in condition, and the NP and MD were not notified. About 21 hours later, the resident developed left-sided facial droop and weakness, was sent to the hospital, and was diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy, leading surveyors to cite a quality of care deficiency and identify Immediate Jeopardy.
A resident with a tracheostomy and severe cognitive impairment experienced two trach dislodgement events during which nursing staff demonstrated lack of competency and preparedness in trach management. During one event, an RN found the trach out and sent the resident to the ED for replacement; during another, the trach came out while trach ties and gauze were being changed, and the RN reported not feeling comfortable replacing the full trach. Another nurse initially inserted a smaller trach because that was what was available at bedside, then later replaced it with the correct size after direction from the NP. Surveyor interviews showed that some nurses did not know how to replace a trach, were unaware of or could not locate complete emergency trach equipment at the bedside, and were unclear about trach sizing and the specific size ordered for the resident. Central supply and leadership staff also showed confusion about trach size designations, and the facility had no written respiratory or trach care policy, relying instead on an external nursing manual.
A resident with severe cognitive impairment, respiratory disorders, and a tracheostomy required ongoing trach care and had care plan directions for emergency management if the tube was coughed out. On two occasions, the trach became dislodged while nurses were providing care, leading to hospital transfers; in one case, staff reinserted the trach but were unsure of correct placement. Interviews showed that an RN and an LVN assigned to the resident did not feel comfortable or did not know how to replace a dislodged trach and were unaware of or untrained in using emergency equipment, while another LVN knew how to replace the trach but had not received trach training or a skills checkoff at this facility. The DON and RCS demonstrated confusion about trach sizes and the specific size ordered for the resident, despite documentation that nurse trach competencies had been marked as met, and the prior ADON reported that most nurses, including those involved, had not attended prior hands-on trach training and were uncomfortable with this care. These findings led surveyors to determine that the facility failed to ensure competent nursing staff for tracheostomy care and emergency response.
A resident with dementia and multiple chronic conditions, who had a known behavior of spitting on floors and walls, was found to have dried, thick mucus covering a large area of the dresser and surrounding walls, along with crayon or pen scribbles on the wall near the bed. Staff, including a CNA and supervisory personnel, acknowledged awareness of the spitting behavior and reported frequent need for cleaning, yet the room was observed in an unsanitary and unpleasant condition. This occurred despite a facility housekeeping policy requiring each occupied room to be cleaned and put in order daily and as needed.
A CNA with a recent assault conviction was hired and worked in the memory care unit after a background check revealed a disqualifying offense, in violation of state law and facility policy. The oversight occurred due to improper screening and lack of follow-up by the previous HRC, and was only discovered during a later personnel file audit.
The facility failed to adhere to food service safety standards, including improper storage of a soiled mop, inadequate air drying of dishes, and the presence of personal food items in the kitchen. These actions could risk foodborne illness for residents.
A facility failed to include depression as a focus area in a resident's comprehensive care plan, despite it being an active diagnosis. The omission occurred when the resident discontinued psychotropic medications, and the focus area listing the medications was removed, inadvertently excluding the depression diagnosis. The MDS RN and Regional Nurse Consultant acknowledged the oversight, emphasizing the importance of monitoring and addressing the resident's depression.
A facility failed to maintain proper infection control when an LVN did not change gloves between administering medications and checking a resident's blood sugar, leading to cross-contamination. The resident, with Type 2 diabetes and impaired cognition, was at risk due to this lapse. The LVN, recently hired and not fully trained in infection control, admitted to the error during a state surveyor's observation.
A resident with Alzheimer's disease and severe cognitive impairment, identified as an elopement risk, was able to leave the facility unsupervised by climbing over a fence using a chair. Staff initially failed to detect the resident's absence despite alarm activation and head counts, and the resident was later found at a nearby location. The facility did not provide adequate supervision or maintain a secure environment, resulting in a deficiency related to accident hazards and resident safety.
A resident with severe cognitive impairment and Alzheimer's disease did not receive her prescribed Memantine 10mg twice daily for 47 days because the medication was not added to her MAR upon admission, despite physician orders and care plan documentation. The omission was only discovered at discharge after family inquiry, and staff confirmed the medication should have been administered throughout the resident's stay.
A resident with diabetes and severe cognitive impairment experienced a critically low blood sugar level, but the nurse on duty did not notify the physician or family, believing the resident was not in distress. The resident's blood sugar dropped to 47 mg/dl, and although it returned to normal after a snack, the incident was not reported as required by facility policy, leading to a delay in medical treatment.
Failure to Notify Provider of Significant Hypotension and Bradycardia During Neuro Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification of a significant change in condition for one resident who was under 72‑hour neurological monitoring following a fall with head injury. The resident was an older male with COPD, dementia, depression, anxiety, dysphagia after stroke, cognitive communication deficit, lack of coordination, and gastrostomy status. His admission MDS showed short‑ and long‑term memory impairment, moderate impairment in decision‑making, fluctuating inattention and disorganized thinking, altered level of consciousness, and wandering 4–6 days per week. He had a history of two or more falls with injury since admission. His care plan addressed falls, helmet use, and neurological checks per facility protocol, but did not identify problems or interventions related to hypotension or bradycardia. Prior to admission to the facility, the resident had been hospitalized for septic shock secondary to pneumonia and influenza A, requiring ICU care, vasopressors, antibiotics, and mechanical ventilation, and was started on Midodrine for hypotension. At the facility, he sustained a fall on 11/19 with a forehead laceration; he was evaluated in the ER, where CT imaging was negative for intracranial bleeding or fracture, and he returned to the facility for continued neurological assessments. Neurological assessment entries on 11/20 and 11/21 documented stable vital signs and normal findings, although one scheduled assessment on 11/21 at 9:45 PM was not documented. On 11/22 at 5:45 AM, a neurological assessment entry documented normal findings and stable vital signs, and additional neurological entries for that date were later signed, but there was no contemporaneous documentation of abnormal neurological findings. The resident’s MAR showed that from 11/8 through 11/21, his BP readings were consistently above 110/60 and his pulse consistently above 60 bpm. On 11/22, his day‑shift BP dropped to 97/52 with a pulse of 56, and a vital signs log entry at 9:09 AM documented a further drop to 81/48 with HR 55. A PRN order for Midodrine 5 mg q8h PRN for systolic BP <90 had been in place since 11/7 but had never been used before. At 9:06 AM on 11/22, an LVN administered Midodrine due to the BP of 81/48 and HR 55 and documented the administration as effective, but there was no further assessment or monitoring documented after this episode and no documentation that the physician was notified of the hypotension, bradycardia, or first‑time use of the PRN Midodrine. Progress notes for 11/22 contained no additional entries after 9:06 AM regarding the resident’s status. On the following day, 11/23 at 5:57 AM, vital signs were recorded as BP 110/56 and HR 60, and a progress note at 5:58 AM documented that the prior PRN Midodrine dose was effective, without describing how effectiveness was determined. At approximately 6:30 AM, staff observed the resident with new left‑sided weakness and facial drooping after a shower, and he was unable to mouth words as he typically did. A change in condition note at 7:08 AM documented left‑sided facial droop, left‑sided weakness, hemiparesis, and vital signs including BP 102/58 and pulse 51. EMS was called for possible stroke, and EMS records noted a pulse of 45 bpm and bilateral lower extremity swelling, with staff reporting onset of symptoms around 6:30 AM. Hospital records later documented that upon evaluation in the emergency department, the resident was hypotensive and diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy. Interviews with the DON, NP, and MD confirmed that the provider was not notified at the time of the 11/22 hypotension and bradycardia episode, and the DON stated she would not have considered the decrease in BP and HR with first‑time PRN Midodrine use to be a change in condition requiring physician notification, despite the facility’s Notification of Changes policy requiring consultation with the physician for significant changes in condition or new treatment.
Failure to Assess and Monitor Resident After Hypotension and PRN Midodrine Use
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and respond appropriately to a resident’s episode of hypotension and bradycardia, and to provide care in accordance with professional standards of practice and the resident’s person-centered care plan. The resident was an older male with COPD, dementia, depression, anxiety, dysphagia after stroke, cognitive communication deficit, lack of coordination, and a gastrostomy. His admission MDS showed short- and long-term memory impairment, moderate impairment in decision-making, fluctuating inattention and disorganized thinking, altered level of consciousness, wandering several days per week, and a history of two or more falls with injury since admission. His care plan addressed falls with interventions such as helmet use and neurological checks per facility protocol, but there were no identified problems or interventions related to hypotension or bradycardia, despite a documented history of severe hypotension and septic shock in a prior hospitalization where he had been treated with vasopressors and started on Midodrine. In the days preceding the cited event, the resident had a fall with a head injury, was sent to the ER, and returned with negative CT results. The facility initiated neurological assessments after the fall, with multiple entries showing stable vital signs and normal neurological findings. However, documentation gaps were present: there was no neurological assessment entry for one scheduled time on 11/21, and several neurological assessment entries for 11/22 were signed late by a nurse who was scheduled as ADON and whose timesheet reflected only a few hours worked that day. The resident’s routine vital signs from 11/8 through 11/21 showed systolic blood pressures consistently above 110 and pulses above 60 bpm. On 11/22, his day-shift blood pressure dropped to 97/52 with a pulse of 56, and the vital signs log recorded a further drop that morning to 81/48 with a heart rate of 55. At approximately 9:06 AM on 11/22, an LVN administered PRN Midodrine 5 mg for the blood pressure of 81/48 and heart rate of 55, in accordance with an existing order to give Midodrine every 8 hours as needed for systolic blood pressure less than 90. The MAR documented this administration as effective, but the progress notes contained no further assessment or monitoring documentation after the 9:06 AM entry on that date, and there were no additional notations on 11/22 indicating ongoing monitoring of the resident’s condition following the hypotensive and bradycardic episode. The neurological assessment form for 11/22 showed normal vital signs and findings at several times, but these entries were signed late, and there was no contemporaneous documentation of assessment immediately after the low blood pressure and heart rate. The NP and MD later confirmed they were not notified of the hypotension and bradycardia on 11/22. Approximately 21 hours after the abnormal blood pressure and heart rate, the resident developed left-sided facial droop and weakness, was found by staff with stroke-like symptoms, and was transferred to the hospital, where he was diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy and admitted to the ICU. The facility’s Notification of Changes policy required informing and consulting with the physician when there is a significant change in the resident’s physical condition, including life-threatening conditions or clinical complications, and when circumstances require a need to alter treatment, such as new treatment. The facility did not have a policy for neurological assessments and the Notification of Changes policy did not include guidance for assessment, identification, or monitoring of a change in condition. The DON stated that neurological assessments were used after unwitnessed falls or possible head injury and that vital signs were part of these assessments, but she did not consider the resident’s decrease in blood pressure and heart rate below baseline, along with the need for PRN Midodrine that had not been previously used at the facility, to be a change in condition requiring physician notification, as the medication was documented as effective. The NP and MD both indicated they would expect administration of PRN Midodrine for low blood pressure and would expect notification if the medication was ineffective, but they were not notified of this episode. The surveyors concluded that the facility failed to assess the resident after the blood pressure of 81/48 and heart rate of 55, failed to monitor and assess his condition after PRN Midodrine was administered, and failed to identify and manage this as a change in condition while neurological assessments were ongoing, leading to the cited quality of care deficiency and the identification of Immediate Jeopardy. An Immediate Jeopardy (IJ) was identified on 4/17/2026 at 4:47 PM related to these failures, and the IJ was removed on 4/19/2026, with the facility remaining out of compliance at a lower severity level while monitoring of corrective actions continued.
Failure to Ensure Competent Tracheostomy Care and Emergency Preparedness
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including tracheostomy care and tracheal suctioning, to a resident with a tracheostomy, in accordance with professional standards, the care plan, and physician orders. The resident had a history of tracheostomy related to laryngeal injury, shortness of breath, other specified respiratory disorders, and severe cognitive impairment, and required trach care and suctioning. The care plan and orders specified use of a Shiley size 6 trach inner cannula, routine trach care every shift, and maintenance of an extra trach tube and obturator at the bedside for tube-out procedures. On two separate occasions, the resident’s trach became dislodged. On the first occasion, an RN entered the room and found the trach out; the resident did not appear in respiratory distress, and the RN notified the nurse practitioner, who ordered transfer to the emergency room. Hospital records documented that the resident was sent for trach replacement due to a dislodged trach, and the trach was replaced via bronchoscopy. On the second occasion, during trach care while the RN was changing the gauze and trach ties, the resident coughed and the trach “blew out.” The RN reported she did not know this could happen and did not feel comfortable replacing the entire trach, only the inner cannula. Another nurse replaced the trach, the resident had difficulty breathing, was placed on oxygen, and was again sent to the hospital, where the ED noted the trach had been reinserted by facility staff who were unsure of correct placement. Surveyor interviews and observations showed that staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in the event of accidental extubation. One LVN stated that if the trach fell out, she would call for help, call the nurse practitioner, and send the resident to the hospital because that was how he breathed, and she would not know how to replace it; when she showed the surveyor the resident’s supplies, there was no trach kit with insertion tool at the bedside. Another RN who assisted during the second dislodgement reported inserting a smaller-sized trach because that was what was available at the bedside, and later replacing it with the correct size after being instructed by the nurse practitioner, but she could not recall the sizes used. Additional interviews with central supply, the DON, and other clinical staff revealed confusion and lack of clear understanding regarding trach sizing, the specific size ordered for the resident, and which emergency trach sizes were present at the bedside. The facility also lacked a written policy on respiratory or trach care and relied on an external nursing manual instead of a facility-specific protocol. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to ensure staff competency, equipment availability, and correct trach sizing for this resident. The Immediate Jeopardy determination was based on three core failures: staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in case of accidental extubation; the resident did not have a same-size trach immediately available at the bedside on at least one occasion when the trach became dislodged; and staff were not consistently knowledgeable about trach sizes or the specific size required by the resident per physician order. These failures occurred despite the resident’s documented need for trach care and suctioning and the care plan requirement to keep an extra trach tube and obturator at the bedside for tube-out procedures.
Removal Plan
- Assess Resident #1 by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
- Validate that physician orders and plan of care for Resident #1's tracheostomy care are being followed.
- Observe the bedside and emergency tracheostomy equipment for Resident #1 and confirm the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
- Reeducate the Director of Nursing by the Respiratory Therapist and provide 1:1 education with return demonstration on tracheostomy care (including supplies), emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate Licensed Nurses on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
- Reeducate LVN A by the Director of Nursing, Respiratory Therapist and/or designee and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate RN A by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate 100% of Licensed Nurses 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Complete re-education with return demonstration for Licensed Nurses who are out on PTO/FMLA/Leave of Absence prior to the start of their next scheduled shift.
- Provide this training to newly hired licensed nurses and require passing a return demonstration during orientation prior to providing care to residents.
- Review new admissions/readmissions with tracheostomies by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and for the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.
Failure to Ensure Competent Nursing Staff for Tracheostomy Care and Emergency Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the specific competencies and skills necessary to care for a resident with a tracheostomy, as required by the resident’s assessments and care plan. The resident was an older male with diagnoses including epileptic seizure, shortness of breath, other specified respiratory disorders, and a tracheostomy related to laryngeal injury. His care plan identified him as being at risk for alterations in respiratory status and directed that a disposable Shiley #6 inner cannula be changed every shift, with extra trach tube and obturator kept at bedside and specific steps to follow if the tube was coughed out. The resident’s MDS showed severe cognitive impairment, dependence for personal care, shortness of breath when lying flat, and a need for trach care and suctioning. On two separate dates, the resident’s tracheostomy became dislodged while under the care of facility nursing staff. In one incident, a progress note documented that a nurse found the trach no longer in place; the resident’s oxygen saturation was 94% and he denied shortness of breath, and he was sent to the hospital where the trach was replaced via bronchoscopy. In a later incident, another progress note documented that while a nurse was replacing the trach tie, the resident coughed and the trach came out; the trach was replaced, the resident had difficulty breathing, was given 2L of oxygen, and was again sent to the hospital. The hospital emergency department record for the second event stated that nursing home staff had put the trach back in after it became dislodged and were unsure if it was in the correct position, though it appeared appropriately positioned on evaluation. Interviews with staff revealed gaps in tracheostomy-related competencies and knowledge. One RN reported that the resident’s trach had dislodged twice on her shifts, that another nurse had to replace the trach on one occasion, that she did not feel comfortable replacing the entire trach (only the inner cannula), and that she did not know the trach could be expelled by coughing. She stated her last trach training was likely in 2023. An LVN assigned to the resident stated that if the trach fell out, she would call the nurse practitioner and send the resident to the hospital immediately and that she would not know how to replace it. Another LVN demonstrated awareness of the emergency trach kit in the room and stated she would replace the trach using the correct size, but also reported she had not received trach training or a skills checkoff at this facility since starting work there. Additional interviews showed that key clinical leaders lacked full understanding of trach sizes and the specific size required for this resident. The DON stated she was not the most knowledgeable about trach sizes and could not explain the different sizes of trachs and inner cannulas. During an observation in the resident’s room, the DON and RCS reviewed trach supply boxes labeled with product codes and the RCS initially interpreted inner cannula diameters from package diagrams, then later reported she had spoken with the RT to clarify that the first number in the label indicated size and that the resident used a size 6 Shiley trach. The nurse practitioner stated that the resident’s trach order for a size 6 inner cannula meant a 6 mm inner cannula and that nursing staff should use a 6 mm inner cannula. The RT explained the meaning of the trach product code and that emergency supplies should include the resident’s trach size and a smaller size. Record review showed that competency assessments for two nurses had been marked as “met” for trach care and emergency decannulation procedures, but the prior ADON reported that most nurses, including these two, had not attended prior hands-on trach training and that they did not feel comfortable providing that type of care. The surveyors determined that these findings demonstrated that multiple licensed nurses, as well as the DON and RCS, lacked the necessary competencies and knowledge regarding tracheostomy care, emergency response to accidental decannulation, and trach sizing for this resident. This failure to ensure competent nursing staff for tracheostomy management led to an Immediate Jeopardy determination related to the resident’s care.
Removal Plan
- Resident #1 was assessed by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
- The Respiratory Therapist validated that physician orders and plan of care for Resident #1's tracheostomy care were being followed.
- The Respiratory Therapist observed the bedside and emergency tracheostomy equipment for Resident #1 and confirmed the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
- The Director of Nursing was reeducated by the Respiratory Therapist and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses were reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
- LVN A was reeducated by the Director of Nursing, Respiratory Therapist and/or designee and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- RN A will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and will receive 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses were reeducated 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses who are out on PTO/FMLA/leave of absence will have the re-education completed and return demonstration prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training and pass a return demonstration during orientation prior to providing care to residents.
- New admissions/readmissions with tracheostomies will be reviewed by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.
- The Director of Nursing and/or designee will monitor compliance with physician orders for tracheostomy care and presence of accurate emergency tracheostomy equipment at the bedside by validating through rounding on residents with a tracheostomy.
- The Director of Nursing and/or designee will monitor compliance with licensed nurse competency in tracheostomy care via observations and competency checks.
- The Director of Nursing and/or designee will monitor compliance with daily verification and documentation of presence of emergency supplies at resident bedside (extra tracheostomy in current size, one size down, and Ambu bag) by rounding on residents with tracheostomy.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional President of Operations to discuss the immediate jeopardy and review the plan of removal.
Failure to Maintain Clean and Sanitary Resident Room Environment
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment for one resident whose room contained extensive dried biological material and wall markings. The resident, an older adult with Alzheimer's disease, heart failure, bipolar disorder, GERD, and COPD, had a documented behavior care plan noting a problem of spitting on the floors and walls, with interventions focused on anticipating needs, providing positive interaction, and discussing and reinforcing why the behavior was inappropriate. During an observation, the resident's dresser and adjacent walls were found covered in dried, thick streaks of mucus in brown, red, and pink colors over an area of approximately 5 feet by 5 feet, and the wall next to the bed had multicolored crayon and/or pen scribbles about 2 feet by 1 foot in size. A CNA reported hearing the resident spit on the walls and stated that nurses and nurse managers were aware of this behavior. The Environmental Supervisor stated that the resident spit so much that staff sometimes had to clean the room twice daily and that if the material stayed too long it became difficult to clean, while also stating the room had been cleaned the previous night. The ADON indicated she did not believe housekeeping was removing the mucus from the walls daily because there was so much present. The facility’s general housekeeping policy stated that each occupied resident room is to be cleaned and put in order daily and as needed, and that sufficient housekeeping and maintenance personnel, equipment, and supplies are to be provided to maintain a safe, clean, orderly, and attractive interior. Despite this policy and awareness of the resident’s spitting behavior, surveyors observed the room in an unsanitary and unpleasant condition, constituting the deficiency.
Failure to Screen Employee with Disqualifying Criminal Background
Penalty
Summary
The facility failed to ensure compliance with state regulations and its own abuse prevention policy by employing an individual who was found guilty of a criminal offense that bars employment in direct care positions. Specifically, a CNA was hired and worked in the memory care unit despite having a recent conviction for assault causing bodily injury, a Class A misdemeanor, for which she received probation. The CNA's personnel file showed that a national background check was conducted at the time of hire, revealing the offense and disposition, but she was still allowed to work with residents. The facility's policy required screening for abuse, neglect, and exploitation, including background checks, but this process was not properly followed in this case. The CNA worked multiple shifts in the memory care unit, which had a census of 19 residents, before her employment was terminated after the new Human Resources Coordinator (HRC) discovered the background check results during a personnel file audit. Interviews with the CNA, HRC, and Interim Administrator confirmed that the CNA's background should have disqualified her from employment, and that the previous HRC had not obtained the necessary documentation or followed up appropriately. The failure to adhere to screening protocols resulted in the employment of an individual with a disqualifying criminal history in a direct care role.
Food Service Safety Deficiencies
Penalty
Summary
The facility was found to have several deficiencies in its food service safety practices. During an observation, a soiled mop was improperly stored head-side down in a mop bucket with dirty water in the utility closet, contrary to the facility's policy that mops should be stored upright to dry properly and prevent bacterial growth. Additionally, in the dish room, plastic bowls and cups were stored face-down on wet trays without air-drying nets, which is against the facility's policy requiring air drying to prevent contamination. Further inspection of the kitchen revealed personal food and beverage items in the food preparation area. A quart-sized container with chopped salad and a large Styrofoam cup with a brown liquid, both belonging to a staff member, were found without proper labeling or covering. This violated the facility's policy that prohibits personal food items in food preparation areas and requires beverages to be covered. These practices could potentially expose residents to foodborne illnesses.
Failure to Include Depression in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3). The deficiency was identified for a resident diagnosed with Alzheimer's disease, depression, and hyperlipidemia. The resident's comprehensive care plan did not include depression as a focus area, despite it being an active diagnosis in the resident's admission MDS. This oversight occurred when the resident discontinued the use of all psychotropic medications, and the focus area listing the medications was removed from the care plan, inadvertently removing the diagnosis of depression as well. During interviews, the MDS RN acknowledged the omission and stated that the diagnosis of depression should have been noted as a focus area to ensure the resident was monitored for signs and symptoms of depression and received appropriate treatment and care. The Regional Nurse Consultant also confirmed that the diagnosis of depression needed to be a focus area in the resident's care plan, even if the resident was not taking medication, to ensure all her needs were addressed. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment.
Infection Control Breach by LVN
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not adhere to proper infection control practices. During an observation, the LVN administered morning scheduled GT medications to a resident while wearing gloves and then proceeded to check the resident's blood sugar without changing gloves. This action was identified as cross-contamination, increasing the risk of infection for the resident. The LVN acknowledged the error, attributing it to nervousness due to being observed by a state surveyor. The resident involved was an elderly male with a history of Type 2 diabetes, hyperlipidemia, and hypertension, and had severely impaired cognition. The Assistant Director of Nursing (ADON) confirmed that the LVN should have sanitized or washed her hands between glove changes to prevent the spread of germs. It was noted that the LVN was recently hired and had not been checked off on infection control practices, despite previous staff training. The facility's policy on infection prevention and control mandates hand hygiene in accordance with established procedures, which was not followed in this instance.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent an elopement. A resident with Alzheimer's disease, severe cognitive impairment (BIMS score of 00), and a history of wandering was identified as an elopement risk. The resident's care plan included interventions such as providing diversions, structured activities, and reorientation strategies, but these measures were not sufficient to prevent the resident from leaving the facility. On the night of the incident, staff reported that alarms sounded at different times, but initial head counts indicated all residents were present, including the resident at risk. Later, it was discovered that the resident was missing, and evidence suggested the resident had used a chair to climb over a fence in the courtyard. The resident was found by a staff member at a nearby drycleaner, fully dressed and carrying personal belongings. Interviews with staff revealed that the resident had not previously attempted to exit the facility, and staff had assumed the resident had basic safety awareness despite cognitive deficits. The facility's failure to provide adequate supervision and to maintain a secure environment allowed the resident to elope. The incident was identified as Immediate Jeopardy due to the risk of harm, serious injury, or death for residents at risk for elopement. The deficiency was based on direct observations, interviews, and record reviews that confirmed the resident's risk status and the facility's lack of effective preventive measures at the time of the event.
Failure to Administer Prescribed Dementia Medication Due to Omission from MAR
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident by not administering a prescribed dementia medication, Memantine 10mg twice daily, as ordered by the physician. The medication was not added to the resident's Medication Administration Record (MAR) until the day of discharge, resulting in the resident missing all doses for a period of 47 days. The resident, an elderly female with diagnoses including metabolic encephalopathy and Alzheimer's disease, was admitted with a physician's order to continue Memantine, which was also documented in her care plan and physician progress notes. However, review of the MARs for July and August showed the medication was not listed or administered during her stay. Interviews with facility staff confirmed that the medication order was present but not transcribed onto the MAR, and the omission was only discovered during the discharge process when the family inquired about the medication. The family member reported noticing increased confusion in the resident during her stay, which was also observed by nursing staff. Facility policy required medication reconciliation at admission, including comparing orders to hospital records and transcribing them accordingly, but this process was not followed, resulting in the resident not receiving her prescribed dementia medication throughout her stay.
Failure to Notify Physician and Family of Resident's Low Blood Sugar
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when there was a need to alter treatment due to a change in the resident's condition. The resident, who had a history of end-stage renal disease, hypertension, type 2 diabetes, and severe cognitive impairment, experienced a significant drop in blood sugar levels. On the day of the incident, the resident's blood sugar was recorded at 47 mg/dl, which is critically low. Despite this, the nurse on duty did not contact the resident's physician or family, as she believed the resident was not in distress and the blood sugar level returned to normal after providing a snack. The nurse, identified as LVN A, administered a snack and drink to the resident and monitored her condition, noting that the resident did not display symptoms of hypoglycemia. However, the nurse did not consider the low blood sugar reading as a change of condition that required notification to the physician or family. This oversight was later acknowledged by the nurse, who admitted that a blood sugar level of 47 could lead to severe consequences such as coma or loss of consciousness. Interviews with the resident's relative and facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the incident was not reported to the appropriate parties in a timely manner. The DON and ADON both stated that the nurse should have notified the physician and family immediately, as per the facility's policy on notification of changes. The failure to follow this protocol resulted in a delay in medical treatment and placed the resident at risk of worsening symptoms.
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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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