Windsor Nursing And Rehabilitation Center Of Morga
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Christi, Texas.
- Location
- 2322 Morgan Ave, Corpus Christi, Texas 78405
- CMS Provider Number
- 455575
- Inspections on file
- 28
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Morga during CMS and state inspections, most recent first.
Two male residents with dementia and severe cognitive impairment were involved in a physical altercation in a lobby area after one resident, who had a documented history of verbal aggression and prior threatening and hitting behaviors, walked across the room and began punching the other resident seated in a wheelchair. The only staff member present, a receptionist, attempted to verbally intervene and then left to call for help as the assault continued, during which both residents fell to the floor while striking each other. The resident in the wheelchair subsequently exhibited head redness, swelling, and ear pain, was found to have an ear injury, and was later diagnosed with an acute left distal clavicular fracture related to the fall. The incident occurred despite an existing care plan identifying the aggressor’s potential for physical aggression and facility policies prohibiting abuse, and the internal investigation later characterized the event as unsubstantiated, stating there was no prior history of this type of behavior for either resident.
A resident with dementia, severe cognitive impairment, and a history of verbal aggression and threatening behavior toward others was not provided with a comprehensive, person-centered care plan addressing these behaviors, despite multiple documented episodes of yelling, rude comments, profane language, and a prior gesture to strike another resident with a cane. Staff notes and assessments over several months recorded anger toward roommates and others, but no behavior care plan with measurable objectives and timeframes was developed until after the resident physically assaulted another resident and then attempted a second physical confrontation that staff were able to prevent. Interviews with facility staff confirmed that such behaviors should have been care planned in accordance with the facility’s comprehensive care plan policy.
A resident with Type 2 DM, dementia, and moderately impaired cognition, who was care planned to use a smoking apron and to be supervised while smoking, sustained a partial-thickness burn to the upper thigh when an activities assistant lit the resident’s cigarette without first applying the required smoking apron. The resident reported dropping the cigarette in her lap, and although the assistant retrieved the cigarette and later brushed an ember from the resident’s lap, the burn was not recognized until a CNA observed a fresh blistered burn during peri-care. Facility policies on abuse/neglect and resident smoking required protections and a safe smoking plan, but these were not followed when the apron was not used before lighting the cigarette.
A cognitively intact male resident with a history of TIA, who had over $1,200 in a facility-managed trust fund and was care planned as independent, requested access to his personal funds on a Friday afternoon but was denied because key staff had left for the day and the ABOM had forgotten the key to the petty cash box. The resident, who believed he should receive a $75 monthly allowance when he wanted it, did not receive any money until the following Monday. The BOM described a practice of using petty cash for withdrawals during weekday business hours, while the Administrator acknowledged there was no specific written policy governing access to resident funds and no staff available on weekends to provide funds, despite existing written procedures on trust fund transactions and petty cash handling.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving the required written notice or explanation. The resident's representative was not informed of the reason for the move, and facility staff could not provide documentation or a clear rationale for the room change, despite policy requiring advance notification.
A resident with end stage renal disease and a dialysis fistula did not receive required assessments for thrill and bruit each shift, as mandated by physician orders and facility policy. Nursing staff admitted to not performing these checks, and the resident confirmed the assessments were not done. Facility leadership acknowledged the deficiency in following established protocols.
Surveyors found that multiple medication and treatment carts contained expired medications, such as insulin Glargine, Promethazine, Tramadol, and Hemorrhoidal Pads, which were not properly labeled or removed as required. Additionally, a staff member's personal cup was found stored with resident medications and supplies, contrary to facility policy. Staff interviews confirmed that these practices did not align with established procedures for medication storage and labeling.
Two elevators used by residents, staff, and visitors consistently had strong foul odors, described as urine and feces, despite frequent cleaning and shampooing of the carpeted floors. Multiple staff, visitors, and residents confirmed the ongoing issue, attributing it to residents having accidents and the presence of carpet, which retained odors. The facility's housekeeping policies require maintaining a clean and odor-free environment, but the elevators remained malodorous.
Surveyors found that all resident rooms with two beds did not meet the required minimum of 80 square feet per resident, with measured room sizes ranging from 149 to 156.5 square feet. The ADM confirmed no changes had been made to the rooms and provided a waiver request for the deficiency.
A resident with severe cognitive impairment and high fall risk was left unsupervised in the therapy gym due to miscommunication among therapy staff, resulting in a fall from her wheelchair and injuries including a hematoma and laceration. The care plan required supervision and frequent rounding, but these interventions were not followed, and the facility's fall prevention policy did not address supervision for high-risk residents.
A resident with a history of behavioral issues struck his cognitively impaired roommate on the forehead with a grabber after repeated interference with personal belongings. The incident, which was not witnessed by staff, resulted in a minor injury and was confirmed through resident and staff interviews as well as facility documentation. The aggressor had a known risk for physical aggression, and the event met the facility's definition of abuse.
The facility did not ensure timely reporting of alleged abuse and injuries of unknown source for two residents with cognitive impairment. In both cases, staff delayed notifying the administrator and appropriate authorities, despite facility policy and recent training on abuse, neglect, and exploitation reporting requirements.
Two residents' care plans were not updated by the interdisciplinary team after changes in their conditions. One resident with severe cognitive impairment had a history of giving money to others that was not reflected in the care plan, while another resident with multiple falls and complex medical needs did not have fall prevention interventions documented. Staff interviews confirmed these omissions were due to oversight and inconsistent care plan updates.
The facility failed to secure medication carts and maintain proper temperature logs for medication storage, leading to potential risks of medication contamination and ineffectiveness. Unlocked carts were found on the 200 and 300 floors, and temperature logs were incomplete in the 300 and 200-floor medication storage rooms. Staff interviews revealed a lack of awareness and training on the importance of securing medications and maintaining accurate temperature records.
A resident with a stage 3 pressure ulcer did not receive proper wound care as the Wound Care nurse failed to pat dry the wound after cleansing, contrary to physician orders. The nurse admitted to missing this step due to nervousness, which could lead to complications like maceration. The resident, with a history of cerebral infarction and contractures, was unable to be interviewed. The DON confirmed the importance of following orders and noted that the nurse was usually compliant with wound care procedures.
The facility's kitchen operations were found deficient in maintaining sanitary conditions. Juice dispenser guns were unsanitary, with nozzles resting in sticky substances and not cleaned after use. Equipment and storage practices were inadequate, with scratched and stained dishes, open spice containers, and a worn frying pan still in use. Staff interviews revealed a lack of awareness and adherence to sanitation practices, with concerns about cross-contamination and resident safety.
A facility failed to maintain a safe environment when a covered needle syringe was found in a resident's room, posing a risk of injury or infection. The resident, who requires enhanced barrier precautions, was unaware of the needle's presence. Staff interviews revealed a lack of awareness and adherence to proper sharps disposal procedures, with the DON acknowledging deficiencies in staff rounding practices and uncertainty about recent in-service training.
A resident with multiple medical conditions did not receive a prescribed nasal spray due to its unavailability in the medication cart. Despite this, several nurses documented that the medication was administered. Interviews and observations confirmed the medication was not given, leading to false documentation. The facility's policy requires accurate documentation and notification if medications are unavailable, which was not followed in this case.
The facility did not meet the required 80 square feet per resident in 46 multiple resident rooms, with room sizes ranging from 120 to 132.3 square feet for two residents. This was identified through observation and record review, despite an existing room size waiver from a previous survey.
A resident with severe cognitive impairment was transferred without a written 30-day notice, proper documentation, or timely notification to the Ombudsman. The transfer was deemed necessary due to the resident's high risk of elopement and the facility's inability to provide extended one-to-one care.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. A male resident with unspecified dementia, severe cognitive impairment (BIMS score of 03), and a history of verbal behaviors toward others had documented episodes of demanding and rude comments toward another resident, yelling at his girlfriend and her neighbor, and making threatening gestures. On one occasion, he tried to hit another resident with his cane after becoming upset, and on another, he hit a resident in the face. His care plan, initiated after these behaviors, identified a potential for physical aggression toward other residents and included interventions such as de-escalation by redirection and monitoring for signs that he posed a danger to himself or others. Another male resident with Alzheimer’s disease, a cognitive communication deficit, and severe cognitive impairment (BIMS score of 07) had no documented history of physical or verbal behaviors toward others on his admission MDS. On the date of the incident, this resident was sitting in his wheelchair at the front desk near the front door, talking to the receptionist and looking around. The first resident was seated approximately 25 feet away in the lobby area. According to the receptionist, the first resident began cursing across the room at the second resident, believing he was looking at his girlfriend, and continued to curse while walking across the lobby toward him. As the first resident crossed the room, the receptionist told him to stop and then ran to call for assistance when he did not listen. The first resident then began punching the second resident in the side and back of the head while the second resident remained in his wheelchair. The second resident cursed back and wrapped his arms around the first resident, and both fell to the floor while still punching each other. Staff and another resident intervened to separate them. A nurse later documented that the second resident had redness and slight swelling to his head and complained of right ear pain, and he was sent to the ER, where an ear injury was noted. A subsequent x-ray revealed an acute left distal clavicular fracture with superior displacement of the clavicle, associated with a fall from his wheelchair during the altercation. At the time of the incident, the receptionist was the only staff member monitoring the first-floor lobby area, and there was no requirement for additional staff presence in that area. The facility’s abuse, neglect, and exploitation policy stated that it would provide protections for each resident’s health, welfare, and rights by implementing policies and procedures that prohibit and prevent abuse, defined as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The facility’s investigation report described that the first resident became upset and agitated when the second resident was talking to a female resident, then walked from his chair toward the second resident while using foul language and proceeded to punch him, resulting in both residents falling to the floor. The report documented that the second resident was evaluated in the ER for an ear injury and later diagnosed with a left distal clavicular fracture related to the fall during the altercation. Despite prior documentation of the first resident’s threatening and physically aggressive behavior toward other residents, the investigation summary concluded the incident was unsubstantiated, stating that both residents had no prior history of this type of behavior. The facility’s failure to prevent the assault and resulting injuries, in the context of known behavioral risks and limited supervision in the lobby area, constituted a failure to ensure residents’ right to be free from abuse and neglect.
Failure to Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s aggressive behaviors. The resident was an older male with unspecified dementia and a history of transient ischemic attack with cerebral infarction, admitted in mid-2024. His Quarterly MDS assessment in late February 2026 showed a BIMS score of 03, indicating severely impaired cognition, and documented that he exhibited verbal behaviors toward others and used a cane for mobility. Despite these findings, there was no care plan in place addressing his verbally or physically aggressive behavior prior to a physical aggression incident at the end of March 2026. Multiple progress notes documented a pattern of verbal aggression and threatening behavior over several months that was not incorporated into a behavior-focused care plan. An activities note from late November 2025 described the resident as very demanding and making rude comments toward another resident. Nursing notes from December 2025 and early January 2026 recorded episodes where he used profane language toward his girlfriend and yelled at another person for walking around in a brief. A social work note dated early January 2026 documented that he was educated about other patients’ rights after he made a gesture to try to hit another resident with his cane when upset. A change of condition assessment from early October 2025 also recorded that he was angry and yelling at his roommate. On March 29, 2026, an incident report and staff interviews described a resident-to-resident altercation in which the resident crossed a room while cursing at another resident and then punched him on the side and back of the head, despite the receptionist’s attempts to verbally intervene. The following day, a social work note documented that he attempted again to engage in physical contact with another resident in an elevator but was stopped by nursing staff. Only after this physical aggression was a care plan initiated on March 30, 2026, which identified potential for physical aggression and included general interventions such as de-escalation by redirection and monitoring for danger to self or others. Interviews with the SW, Administrator, and MDS nurse confirmed that prior verbal and threatening behaviors should have been care planned and that the facility’s policy required comprehensive care plans with measurable objectives and timeframes to meet identified medical, nursing, and psychosocial needs.
Failure to Apply Required Smoking Apron Resulting in Resident Burn
Penalty
Summary
The facility failed to ensure a resident’s environment remained as free of accident hazards as possible and failed to provide adequate supervision to prevent accidents when a resident sustained a cigarette burn while smoking. The resident was an older female with Type 2 diabetes and dementia with behavioral disturbances, and a BIMS score of 09 indicating moderately impaired cognition with intermittent disorganized thinking. Her care plan, initiated after the incident, documented that she had sustained a burn to her left thigh while smoking and included an intervention to educate her on safe smoking practices. Another care plan, initiated earlier and later revised, specified that she required a smoking apron and supervision while smoking. On the date of the incident, the activities assistant (AA) reported that the resident was very impatient to smoke. The AA gave and lit the resident’s cigarette without first applying the required smoking apron, despite the resident’s care plan indicating she needed it. The AA stated she did not initially see the resident drop the cigarette, but the resident said she had dropped it, and the AA picked the cigarette up from the resident’s lap and handed it back to her. While the AA was then putting on the smoking apron, the resident reported that the area was still burning, and the AA observed and knocked an ember off the resident’s lap but did not notice a hole in the clothing. Later, a CNA discovered a fresh partial-thickness burn with a fluid-filled blister and surrounding redness on the resident’s upper left thigh during peri-care and reported it to the charge nurse. The facility’s policies on abuse, neglect, and resident smoking required protections against neglect and the development of a safe smoking plan, but the resident was not protected from neglect when the apron was not applied before lighting the cigarette.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage his personal funds by not providing timely access to money held in the resident trust fund. The resident was an adult male with a history of transient cerebral ischemic attack and an intact cognition status, evidenced by a BIMS score of 14 on a recent MDS, and was care planned as independent in meeting emotional, intellectual, physical, and social needs. His resident statement showed a trust fund balance of $1,250.37. The resident reported that on a Friday he requested some of his money but the facility would not give it to him, and that although he was supposed to receive $75.00 per month, sometimes he did not receive it when he wanted it. The Business Office Manager (BOM) explained that residents’ checks were applied to room and board, with remaining funds deposited into trust accounts, and that Medicaid allowed $75.00 for resident spending. She stated that when residents requested withdrawals, a form was completed and money was taken from a petty cash box, which was replenished as needed, and that residents typically waited no more than about two hours. However, the Assistant Business Office Manager (ABOM) stated that on a Friday afternoon the resident came to the business office requesting his money and was told the BOM had left for the day and would not return until Monday. Although the ABOM had access to petty cash, she had forgotten her key at home, so the resident did not receive any funds that day and did not get his money until the following Monday. The Administrator confirmed there was no specific written policy for providing access to resident funds, that access was limited to business hours on weekdays, and that no one was available on weekends to provide funds, despite the facility’s written procedures addressing resident trust fund transactions and petty cash reconciliation.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Required Written Notice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide a resident with written notice, including the reason for a room change, prior to relocating the resident to a different room. The resident, who had severe cognitive impairment and multiple complex medical diagnoses including Multiple Sclerosis, quadriplegia, Alzheimer's disease, and major depressive disorder, was dependent on staff for all activities of daily living and preferred to spend time in his room. Despite facility policy requiring a 30-day written notice to the resident or their representative before any room change, there was no documentation or notification provided to the resident's representative regarding the reason for the move. Interviews with the resident's family member and facility staff confirmed that no written or verbal explanation was given prior to the room change, and the family member only learned of the move after it occurred. The family member reported that the resident was comfortable with his previous roommate and struggled with the new room environment, which was too cold for him. Facility staff, including the Social Worker and DON, were unable to provide documentation or a clear reason for the room change, and acknowledged that the required notification process was not followed in this instance.
Failure to Perform Required Dialysis Fistula Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care in accordance with professional standards of practice. Specifically, nursing staff did not consistently assess the resident's dialysis fistula for thrill and bruit every shift, as required by physician orders and facility policy. Observation revealed that a nurse placed a stethoscope over the fistula to listen for bruit but did not properly assess for thrill. Interviews with nursing staff confirmed that the required assessments were often not performed, with one nurse stating that she either forgot or was too busy, and believed that the checks were unnecessary since the resident's fistula was assessed at the dialysis center. The resident involved was an adult male with diagnoses including alcoholic cirrhosis of the liver with ascites, congestive heart failure, and end stage renal disease requiring dialysis. The resident had intact cognition and confirmed that his fistula was not being checked by facility nurses. Facility leadership acknowledged that the assessments should have been performed each shift and that the failure to do so was not in line with established orders and policy. The facility's policy required checking for thrill and bruit each shift and monitoring for bleeding upon return from dialysis.
Failure to Properly Label, Store, and Dispose of Medications and Personal Items in Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were properly labeled and stored according to professional standards on multiple medication and treatment carts. Specifically, a vial of insulin Glargine on the 2nd Floor Nurse-Med-Cart-A was found to be expired, discontinued, and not labeled with an open or expiration date. Additionally, a container of Hemorrhoidal Pads on the 2nd Floor Treatment Cart and cards of Promethazine and Tramadol on the 3rd Floor Nurse-Med-Cart-B were found to be expired but not removed from the carts. These expired medications and supplies were accessible and had not been disposed of as required by facility policy. Further, the 3rd Floor Treatment Cart was found to contain a large personal aluminum cup with a straw, which belonged to a staff member, in the bottom drawer alongside resident medications and supplies. Staff interviews confirmed awareness that personal items should not be stored with medications due to the risk of cross-contamination. Facility policy required medication carts to be kept clean, organized, and free of expired medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and personal items in the carts.
Persistent Foul Odors in Elevators Due to Inadequate Environmental Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two of three elevators, as both Elevator 1 and Elevator 2 were found to have persistent foul odors, described as smelling of urine and feces. Multiple observations by the surveyor over two consecutive days confirmed the presence of strong, offensive odors in both elevators. Interviews with staff, visitors, and residents corroborated these findings, with several individuals reporting ongoing complaints about the smell. The MDS Coordinator, WCN, HS, RD, ADM, MS, and SW all acknowledged the issue, attributing the odors primarily to the carpet installed in the elevators and to residents having accidents in them. Despite frequent cleaning, including daily and as-needed shampooing and vacuuming, the odors persisted. The facility's General Housekeeping Policies require maintaining the environment free from offensive odors through proper housekeeping practices, not by masking odors with deodorizers. However, the report indicates that the elevators continued to have foul odors despite adherence to cleaning routines. Housekeeping staff did not keep a log of cleaning activities but indicated an intention to start one. The issue was further compounded by the presence of carpet in the elevators, which was identified as a contributing factor to the persistent odor problem.
Resident Room Size Requirements Not Met
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms, as mandated by regulations. During a recertification survey, all 89 resident rooms were measured using a laser measuring device, and it was found that rooms with two beds measured between 149 and 156.5 square feet, which does not meet the minimum requirement of 80 square feet per resident. The deficiency was observed in all 89 rooms listed in the report, each containing two beds. Record review of the Health and Human Services Form 3740 Bed Classifications confirmed the room configurations, and the administrator provided a letter requesting a room size waiver for the affected rooms. The administrator also stated that there had been no changes to the rooms. The report notes that this failure could restrict the amount of resident care equipment and personal effects that could be accommodated in these rooms and limit residents' ability to move about, but does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, high fall risk, and a history of multiple falls was left unsupervised in the therapy gym, resulting in a fall from her wheelchair. The resident, who required substantial assistance for activities of daily living and had a BIMS score of 0, was dependent on staff for mobility and safety. On the day of the incident, the resident was brought to the therapy room by a CNA and left in the care of a therapist. The therapist subsequently left the area, believing another staff member would supervise the resident, but there was a miscommunication and no one was directly supervising her. The resident was found on the floor with a hematoma and laceration above her left eyebrow. Documentation and staff interviews confirmed that the resident was left unattended due to a lack of clear hand-off communication between therapy staff. The care plan for the resident included interventions such as frequent rounding, supervision in the therapy room, and staff anticipation of needs, but these were not followed at the time of the incident. The facility's fall prevention policy did not specifically address supervision of high fall risk residents. Multiple staff statements indicated that the failure to ensure direct supervision and a proper hand-off process led to the resident being left alone, which allowed the fall to occur. The event was unwitnessed, and the resident required hospital evaluation for her injuries. The deficiency was attributed to inadequate supervision and a breakdown in staff communication regarding responsibility for the resident's safety.
Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident. One resident, who had a history of potential physical aggression and required supervision for all activities of daily living, struck his roommate on the forehead with a grabber after the roommate repeatedly touched his personal belongings. The incident resulted in a small, reddened area on the victim's forehead, which resolved within minutes. The aggressor admitted to hitting his roommate because he would not stop touching his grabber, and the event was confirmed by staff and documented in the facility's records. The resident who was struck had moderate cognitive impairment, required substantial assistance with daily activities, and was dependent on a wheelchair. At the time of the incident, he did not display behavioral issues and was taking multiple psychotropic medications. The altercation was not witnessed by staff, but was reported by another resident who heard arguing and shouting. Upon investigation, staff found the aggressor cursing at the victim, who was able to indicate where he had been hit but could not verbally describe the event. Facility records indicated that the aggressor had a known history of behavioral issues, including grumpiness and resistance to care, and had previously experienced roommate conflicts. Despite these known risks, the altercation occurred, resulting in physical contact and a minor injury. The facility's policy defines abuse as the willful infliction of injury, and the incident met this definition based on the deliberate action taken by the aggressor.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported within the required timeframes to the administrator and appropriate authorities. Specifically, two residents were involved in incidents where reporting did not occur as mandated by facility policy and federal regulations. In one case, an allegation of abuse concerning a male resident with severe cognitive impairment and multiple comorbidities was not reported to the administrator until four days after the incident, despite policy requiring immediate notification. In another instance, a certified nursing assistant (CNA) observed bruising on a male resident with moderate cognitive impairment and a history of falls but did not report the injury of unknown source to the administrator until two days later. The CNA assumed the injury had already been reported and did not act immediately, even though the bruising was significant and the resident was unable to communicate discomfort. The wound care nurse and DON both confirmed that the bruising should have been reported immediately, and the wound care nurse was not informed until two days after the initial observation. Interviews with staff indicated that they were aware of the types of abuse, neglect, and exploitation, and had received recent training on reporting requirements. However, despite this training, the required immediate reporting did not occur in these two cases. Facility policy clearly outlined the need for prompt reporting of such incidents, but the actions taken did not align with these procedures, resulting in a deficiency.
Failure to Revise Care Plans After Resident Status Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident with Alzheimer's disease and severe cognitive impairment, the care plan was not updated to reflect a history of attempting to give money to other residents and staff. Interviews with the DON, ADON, and MDS Coordinator confirmed that this behavior should have been care planned to inform staff and provide individualized care, but it was overlooked. Another resident with multiple diagnoses, including stroke, dementia, and severe cognitive impairment, had a history of multiple falls. Although the resident required significant assistance with daily activities and had interventions such as a helmet, fall mat, and frequent rounding discussed by staff, these interventions were not documented in the care plan. The DON acknowledged that these fall prevention measures were not entered into the care plan, and the care plan lacked updates regarding the resident's high fall risk and other relevant diagnoses, such as PTSD. Facility policy required that the MDS Coordinator and interdisciplinary team discuss resident condition changes and update care plans accordingly. However, interviews revealed that care plan updates were inconsistently performed, with responsibilities shared among the MDS Coordinator, ADONs, nurses, and the DON. The lack of timely and accurate care plan revisions for both residents was attributed to oversight and failure to follow established procedures.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls. On the 200-floor, a treatment/medication cart was observed unlocked by the nurse's station, with its drawers facing outward, making medications easily accessible. LVN A, who was on duty, stated that she was not aware the cart was unlocked and had not been in-serviced on the importance of keeping it locked. Similarly, on the 300-floor, another medication cart was found unlocked and unattended, with LVN D acknowledging that it had been left unsecured while assisting a resident. In addition to the unsecured medication carts, the facility also failed to maintain proper temperature logs for medication storage refrigerators. On the 400-floor, the temperature log for the medication refrigerator was incomplete, with missing entries for specific dates, and a brown sticky substance was found on the bottom shelf, indicating a lack of cleanliness. LVN E and other staff members acknowledged the potential for contamination and the importance of maintaining accurate temperature logs to ensure medication efficacy. The 300 and 200-floor medication storage rooms also had incomplete temperature logs, with missing entries for certain dates. Interviews with the DON and ADON highlighted the responsibility of nurses on both shifts to check and log temperatures, as well as to maintain cleanliness in the medication storage areas. The failure to record temperatures and clean spills could lead to medications becoming ineffective or contaminated, posing a risk to resident health.
Failure to Follow Wound Care Protocol for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident #46, who had a stage 3 pressure injury on the left posterior ischium. The physician's orders required the wound to be cleansed with a wound cleanser, patted dry, and then have a barrier cream applied daily. During an observation of wound care, the Wound Care nurse cleansed the wound and applied the barrier cream without patting the area dry, as was ordered. The nurse admitted to missing this step due to nervousness and acknowledged the importance of following the physician's orders to prevent potential complications such as maceration, which could delay healing. Resident #46, a male with a history of cerebral infarction, contractures, and muscle atrophy, was unable to be interviewed. The Director of Nursing (DON) confirmed the importance of adhering to physician orders and noted that an in-service training on following doctor's orders and infection control was conducted following the incident. The DON also mentioned that the Wound Care nurse was usually observed to perform wound care correctly and that the wound care doctor had not previously noted any issues with the nurse's performance.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The juice dispenser guns were found unsanitary, with one gun's nozzle resting in a sticky red substance on a cardboard box and the other touching a cabinet. Both guns had a buildup of red and black substances, indicating they were not cleaned after each use as required. Additionally, there were personal items, such as open soda bottles, in the prep area and refrigerator, which is against facility policy. The kitchen equipment and storage practices were also found lacking. Many coffee cups, juice glasses, and plastic bowls were scratched and stained, yet they were on the clean rack and ready for use. The sugar bin and several spice containers were left open, exposing contents to air, which could lead to contamination. A worn non-stick frying pan was still in use, despite the risk of the surface flaking into food. The facility's cleaning schedule appeared complete, but the actual cleanliness of the kitchen did not reflect this. Interviews with staff revealed a lack of awareness and adherence to proper sanitation practices. The Food Service Manager (FSM) acknowledged the issues but was unaware of some conditions, such as the underside of the holding table shelf being dirty. Staff expressed concerns about the potential for cross-contamination and the risk of making residents sick, but there was a fear of repercussions for speaking up. The facility's policies on cleaning and personal items were not provided upon request, indicating a possible gap in training and enforcement.
Failure to Maintain Safe Environment Due to Improper Sharps Disposal
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident #273, as well as other residents, staff, and the public. During an observation, a surveyor found an empty covered needle syringe on the dresser in Resident #273's room. The resident, who has intact cognition and requires enhanced barrier precautions due to an open wound and wound vacuum, was unaware of the needle's presence and denied receiving any injections. The presence of the needle posed a risk of injury or infection to anyone who might come into contact with it. Interviews with staff revealed a lack of awareness and adherence to proper disposal procedures for sharps. LVN B, who was on duty at the time, was unaware of the needle's presence and admitted to not being recently in-serviced on sharps disposal. The DON speculated that the needle might have been left by the previous night nurse, LVN C, during wound care activities. The DON acknowledged that the presence of the needle was a safety risk and highlighted deficiencies in staff rounding practices, as well as uncertainty about when the last in-service training on rounding was conducted.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that sufficient staff with the appropriate competencies and skill sets were available to provide nursing and related services, specifically in the administration of medication to a resident. This deficiency was identified during a review of medication administration for a resident who had multiple medical conditions, including orthopedic aftercare following surgical amputation, congestive heart failure, type 2 diabetes, and chronic kidney disease. The resident had an order for Alkalol Saline Nasal Solution to be administered daily, but the medication was not available in the medication cart or storage room, and it was not administered as ordered. The medication administration records (MAR) indicated that the nasal spray was documented as administered on several occasions by different nurses, but observations and interviews revealed that the medication was not actually given. The WCN, who was the charge nurse on the day of observation, confirmed that the nasal spray was not in the medication cart and was advised by the nurse practitioner to obtain it from the pharmacy. However, the pharmacy indicated that the nasal spray was an over-the-counter medication and should be obtained by central supply. Interviews with the resident's family member and the resident himself confirmed that the nasal spray had not been administered since the resident's admission to the facility. The facility's Medication Administration Policy and Procedure outlined the proper steps for medication administration and documentation, including the requirement for nurses to document medications as they are given and to notify appropriate personnel if a medication is not available. Despite these guidelines, the nurses involved documented the administration of the nasal spray without actually administering it, leading to false documentation. The Director of Nursing (DON) acknowledged the issue and indicated that the nurses involved would be disciplined and retrained on medication administration and documentation.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in 46 multiple resident rooms out of a total of 90 resident rooms. The rooms in question measured between 120 and 132.3 square feet, which is insufficient for accommodating two residents per room as required. This deficiency was identified through observation and record review, specifically referencing the facility's Bed Classification Form 3740 dated 06/18/24. An existing room size waiver from a recertification survey exit dated 01/14/22 was noted during offsite facility reviews, but the current room sizes still did not meet the necessary standards for resident space.
Failure to Provide Proper Notice and Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure the notice of transfer or discharge was made at least 30 days before the resident was transferred or discharged. Specifically, Resident #1, who had severe cognitive impairment and was at risk for elopement, was transferred without a written 30-day notice. The facility did not document the discharge appropriately and failed to contact the Ombudsman in a timely manner. The resident's progress notes indicated that the transfer occurred on 3/18/2024, but the Ombudsman was only informed on 3/19/2024. Additionally, the reasons for the transfer were not recorded in the resident's medical record as required by the facility's policy. Interviews with the Social Worker and Nurse Practitioner revealed that the transfer was deemed necessary due to the resident's high risk of elopement and the facility's inability to provide 30 days of one-to-one care. The Social Worker informed the resident's family member about the transfer, who initially disagreed but later accepted after being told they had five days to find an alternative placement. The Administrator justified the immediate transfer by citing the resident's urgent medical needs and the risk posed to other residents. However, the facility's Transfer and Discharge policy requires documentation of the necessity for the transfer and notification to the resident, their representative, and the Ombudsman as soon as practicable, which was not adequately followed in this case.
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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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