Windsor Nursing And Rehabilitation Center Of Raymo
Inspection history, citations, penalties and survey trends for this long-term care facility in Raymondville, Texas.
- Location
- 1700 S Expressway 77, Raymondville, Texas 78580
- CMS Provider Number
- 675475
- Inspections on file
- 32
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Windsor Nursing And Rehabilitation Center Of Raymo during CMS and state inspections, most recent first.
A resident with dementia, schizophrenia, neurocognitive disorder, severe cognitive impairment (BIMS 03), and total dependence on staff for ADLs was observed in bed wiggling and calling out without a call light within reach; the call light was found on the floor beside the nightstand. The resident’s care plan documented inability to use the call light due to dementia and required the call light to be reachable for family or staff to request assistance, with frequent monitoring and rounding. The ADON stated that a CNA had not ensured the call light was in reach, and the CNA reported the resident’s movement during repositioning likely caused the call light to fall, acknowledging it should have been accessible. The DON and facility policy both specified that staff must ensure call lights and frequently used items are within residents’ reach each time staff leave the room.
A resident with dementia, urinary incontinence, and an indwelling/foley catheter was placed under enhanced barrier precautions (EBP), as evidenced by door signage and availability of gowns and gloves, but the quarterly care plan did not include EBP despite the catheter-related need. Record review showed no physician order for EBP, and interviews with an RN and the DON confirmed that facility protocol required both an order and care plan entry for EBP, which were absent. This omission occurred even though the resident’s MDS documented the indwelling catheter and the facility’s comprehensive care plan policy required services to be described to meet identified medical and nursing needs.
A resident with dementia, urinary incontinence, and an indwelling/foley catheter was placed under Enhanced Barrier Precautions (EBP), as evidenced by EBP signage and PPE outside the room, but the clinical record lacked both an EBP order and documentation in the care plan. An RN/MDS nurse confirmed that facility protocol required an order when a resident was under EBP and that no such order was present in the EMR. The DON also stated that an order was required so staff would know what precautions to take and acknowledged there was no facility policy related to physician orders, resulting in an incomplete and inaccurate clinical record for the resident.
A resident with dementia, bladder-neck obstruction, urinary incontinence, and an indwelling Foley catheter was on Enhanced Barrier Precautions (EBP) with signage and PPE available at the room entrance. A CNA performed peri-care, a high-contact activity identified in the facility’s EBP policy as requiring gown and gloves, but only wore gloves and did not don a gown, later stating she was in a hurry and forgot. Observation confirmed the absence of a used gown in the room’s PPE disposal area, and both an RN and the DON verified that EBP, including gown and glove use, was required for this resident during peri-care under the facility’s infection control policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A LTC facility failed to maintain an effective Infection Prevention and Control Program, leading to several deficiencies. Issues included the absence of Enhanced Barrier Precaution (EBP) signs and PPE for a resident with a multidrug-resistant organism infection, improper hand hygiene during medical procedures, and failure to implement EBP for a resident with a gastrostomy tube. Staff interviews revealed confusion and lack of awareness regarding infection control responsibilities, posing a risk of cross-contamination and infection spread.
The facility failed to maintain resident dignity during mealtime as a CNA was observed standing while feeding two residents who required assistance. Both residents, diagnosed with conditions like Alzheimer's and Dementia, were observed looking up at the CNA, indicating a lack of respect and dignity. Interviews confirmed that standing while feeding is against facility policy, which requires staff to be seated to enhance resident quality of life.
The facility failed to ensure safe hot water temperatures in a resident's bathroom, with temperatures recorded at 114 degrees Fahrenheit, exceeding the recommended range of 100-110 degrees. Two residents, both severely cognitively impaired, were affected. The Maintenance Director acknowledged the issue, noting daily checks and adjustments to the water heater. No injuries or grievances were reported in the facility's logs.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, including ESBL-related urinary tract infection and cognitive impairment. The oversight occurred due to the admission over a holiday weekend, and the baseline care plan did not address necessary enhanced barrier precautions. Interviews with the ADON and DON highlighted the importance of the care plan for guiding resident care, but it was not completed as required by facility policy.
A facility failed to properly store medications, allowing unauthorized access to a medicated cream found in a resident's room. The resident, with specific orders for other treatments, did not have an order for the zinc oxide cream discovered. Staff interviews revealed confusion over who left the cream, and the facility's policy mandates that only nurses administer medications. This incident highlights a breach in medication management protocols.
The facility failed to ensure all food items in the kitchen were labeled and dated, as observed during a survey. Unlabeled and undated items were found in the refrigerators and dry storage, despite staff training and established policies. The Dietary Manager and staff acknowledged their responsibility for labeling and dating food items, but the practice was not consistently followed.
A resident with severe cognitive impairment and a history of falls sustained a head injury from an unwitnessed fall, which was not reported to the State Survey Agency within the required timeframe. The facility's staff were either unaware or did not recall the incident, and the care plan lacked documentation of the fall or preventive measures. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A resident with severe cognitive impairment was transferred to a hospital after a fall, but the facility failed to provide a written notice of the bed-hold policy to the resident's representative. The Business Office Manager only obtained verbal consent, contrary to the facility's policy requiring a signed notice. Despite the availability of rooms, the facility did not adhere to its policy of providing written notice within 24 hours of an emergency transfer.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a significant laceration requiring stitches. The LTC facility failed to report the incident to the State Survey Agency within the required 24-hour timeframe, potentially increasing risk for all residents. Interviews revealed that the DON and Administrator were responsible for reporting, but the report was delayed.
A resident with severe cognitive impairment and high fall risk sustained a head injury requiring sutures after a fall. The LTC facility failed to report the incident to the State Survey Agency within the required 2-hour timeframe for serious injuries. Staff discovered the resident on the floor with a head laceration, and emergency services were activated. The facility delayed reporting until hospital confirmation of the injury's severity, contrary to immediate reporting regulations.
A resident with a new colostomy was admitted to a facility without physician orders for colostomy care, treatment, or monitoring. Despite a care plan indicating the need for colostomy management, no orders were documented. Nursing staff were unclear about the responsibility for obtaining and documenting these orders, leading to the oversight. The DON confirmed the absence of orders but stated that the resident was receiving care from experienced staff. The facility lacked a specific policy for inputting physician orders for colostomy care.
A resident with a surgical incision was not properly documented in their skin assessments, despite facility policy requiring comprehensive documentation of all skin-related issues. The LVN responsible for the assessments admitted to the oversight, which was confirmed by the DON. This failure to document could impact the resident's care and treatment.
A resident with severe cognitive impairment and a stage 4 pressure ulcer had incomplete documentation in her Treatment Administration Records for wound care. Nursing staff admitted to performing the care but failing to document it, contrary to facility policy. The Director of Nursing confirmed the lapses and noted that the facility had not been reviewing charts for missed documentation at the time.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Surveyors identified a failure to reasonably accommodate a resident’s needs and preferences by not ensuring her call light was within reach. The resident was an elderly female with dementia, schizophrenia, type 2 diabetes mellitus, neurocognitive disorder, cognitive communication deficit, and arthritis, who was re-admitted in late April 2026 and served as her own representative. A quarterly MDS dated 4/13/2026 documented a BIMS score of 03, indicating severe cognitive impairment, and showed she was totally dependent on staff for toileting, showering, dressing, and locomotion, using a wheelchair. Her care plan problem stated she was unable to use the call light due to dementia, with a goal that the call light be reachable for family or staff to request assistance, and an intervention of monitoring and rounding frequently. On 4/28/2026 at 12:04 p.m., surveyors observed the resident in bed in her room, wiggling and calling out, with no call light within reach; the call light was found on the floor beside her nightstand. At 12:05 p.m., the resident stated she wanted cookies and milk. The ADON stated that CNA A must not have placed the call light within reach when assisting the resident and confirmed that call lights were to be in reach of all residents, including this resident. At 12:30 p.m., CNA A reported he was unaware the call light was not within reach, acknowledged it should have been, and explained the resident moved a lot in bed during repositioning and the call light must have fallen; he also stated the resident could have tried to get out of bed unassisted and hurt herself. On 4/29/2026 at 3:30 p.m., the DON stated staff were expected to ensure all frequently used items, including the call light, were within reach each time they exited a resident’s room, and that although this resident would normally call out if she needed something, the call light still needed to be within reach. Facility policy dated 10/13/2022 required staff to ensure call lights were within reach of residents and secured as needed.
Failure to Care Plan and Obtain Order for Enhanced Barrier Precautions for Catheterized Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident requiring enhanced barrier precautions (EBP). The resident was an older male with dementia, bladder-neck obstruction, urinary incontinence, and a cognitive communication deficit, admitted with an indwelling/foley catheter. His quarterly MDS showed a BIMS score of 09, indicating moderately impaired cognition, and documented the presence of the indwelling catheter. However, review of his quarterly care plan dated 12/26/25 showed that the need for EBP related to his indwelling/foley catheter was not included, despite facility policy requiring comprehensive care plans to address identified medical, nursing, and psychosocial needs. During observation, the resident’s room displayed EBP signage, and gowns and gloves were available outside the room with a trash can inside near the exit, and the resident was seen in bed with an indwelling/foley catheter and a privacy cover on the drainage bag. In interviews, the MDS RN confirmed that the resident’s catheter required EBP and acknowledged that EBP was neither care planned nor supported by a physician’s order in the electronic medical record. The DON stated that facility protocol required an order for EBP and that EBP must be included in the care plan so staff would know what precautions to take during high-contact care. The DON also reported that the facility did not have a policy related to physician’s orders, and the existing Comprehensive Care Plans policy required services to be described to meet the resident’s highest practicable well-being, which was not done in this case for EBP.
Failure to Maintain Complete Clinical Record and EBP Order for Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with accepted professional standards and practices for one resident who required Enhanced Barrier Precautions (EBP). The resident was an older male with dementia, bladder-neck obstruction, urinary incontinence, and a cognitive communication deficit, and he had an indwelling/foley catheter. His quarterly MDS showed a BIMS score of 9, indicating moderately impaired cognition. Review of his quarterly care plan dated 12/26/25 did not include that he required EBP due to his indwelling/foley catheter, and review of his electronic medical record revealed there was no provider order for EBP, despite facility protocol requiring such an order when a resident is under EBP. During observation, the resident’s room displayed EBP signage on the door, with gloves and gowns available outside the room and a trash can inside near the exit, and the resident was in bed with an indwelling/foley catheter and a privacy cover on the drainage bag. In interviews, the RN/MDS nurse confirmed that the resident had an indwelling/foley catheter that required him to be under EBP and acknowledged that an order was required but not present in the record. The DON stated that the facility’s protocol required an order for EBP so staff would know what precautions to take during high-contact care and confirmed there was no facility policy related to physician’s orders. This lack of an EBP order and omission from the care plan constituted incomplete and inaccurate clinical documentation for the resident.
Failure to Follow Enhanced Barrier Precautions During Peri-Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident requiring EBP during high-contact care. The resident was an older male with dementia, bladder-neck obstruction, urinary incontinence, and an indwelling Foley catheter, and his care plan included catheter-related interventions. EBP signage, gowns, and gloves were present outside his room, and a trash can for discarding PPE was positioned inside the room near the exit. On observation, a CNA exited the resident’s room carrying a clear plastic bag containing a soiled brief and gloves, while the trash can inside the room was empty and there was no used gown in either the bag or the trash can, indicating that a gown had not been used. In an interview immediately following the observation, the CNA stated she had transferred the resident from the living room to his room and performed peri-care, and admitted she did not don a gown, wearing only gloves because she was in a hurry and forgot to gown up. She acknowledged that not gowning could result in cross-contamination and reported she had been regularly in-serviced on infection control, including EBP. The RN covering the floor and the DON both confirmed that the resident was under EBP due to having an indwelling/foley catheter and that EBP guidelines, including use of gown and gloves, should be followed during high-contact activities such as peri-care. The facility’s EBP policy defined EBP as targeted gown and glove use during high-contact resident care activities and listed changing briefs or assisting with toileting as such activities, establishing that the CNA’s failure to wear a gown during peri-care was not in accordance with facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to infection control practices. One significant issue was the failure to post Enhanced Barrier Precaution (EBP) signs and provide personal protective equipment (PPE) gowns in or near the room of a resident with a multidrug-resistant organism (MDRO) infection. Interviews with staff revealed confusion and lack of awareness regarding responsibilities for posting EBP signs, with the admitting nurse, Assistant Director of Nursing (ADON), and floor nurses all cited as responsible. The absence of EBP signage and PPE could lead to the spread of infection among residents and staff. Another deficiency involved improper hand hygiene practices during medical procedures. For instance, a registered nurse (RN) failed to sanitize hands after touching a privacy curtain and before donning gloves, subsequently contaminating a resident's gastrostomy tube during medication administration. Similarly, a certified nursing assistant (CNA) did not wash hands or use hand sanitizer between glove changes during wound care for another resident. These lapses in hand hygiene were acknowledged by the staff involved, who cited nervousness and oversight as reasons for their actions. The lack of adherence to proper hand hygiene protocols poses a risk of cross-contamination and infection spread. Additionally, the facility did not implement Enhanced Barrier Precautions for a resident with a gastrostomy tube, as required by the facility's policy. The absence of EBP signage and PPE use was observed, and staff interviews indicated a lack of understanding of when and how to apply these precautions. The Director of Nursing (DON) and ADON acknowledged the importance of EBP in preventing infections but did not ensure consistent implementation. These deficiencies highlight significant gaps in the facility's infection control practices, potentially compromising resident safety.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime, as observed with two residents who required assistance with eating. CNA D was observed standing while feeding both residents during lunch, which is against the facility's policy that requires staff to be seated to maintain resident dignity. Resident #5, diagnosed with Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease, required assistance with eating due to an ADL self-care performance deficit. Similarly, Resident #12, diagnosed with Dementia and Cerebral Infarction, also required assistance with eating. Both residents were observed looking up at CNA D while being fed, indicating a lack of dignity and respect in the feeding process. Interviews with CNA D, the ADON, and the DON confirmed that standing while feeding residents is not respectful and violates the residents' dignity. CNA D admitted to standing due to back pain, despite being aware of the requirement to sit while feeding residents. The facility's policy, implemented on 1/13/23, emphasizes treating each resident with respect and dignity, and requires staff to be seated while feeding residents to maintain or enhance their quality of life. The failure to adhere to this policy was identified as a deficiency in the care provided to the residents.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable environment by not ensuring that the hot water temperatures in the bathroom sinks of two residents' rooms were below 110 degrees Fahrenheit. Specifically, the hot water temperature in the bathroom sink of a room occupied by two residents was recorded at 114 degrees Fahrenheit. This was observed during a survey conducted with the Maintenance Director, who acknowledged that the water temperature should be between 100 and 110 degrees Fahrenheit. The Maintenance Director stated that he conducts daily rounds, checking at least one room in each hall, and had adjusted the water heater temperature earlier that day. The residents involved were both severely cognitively impaired, with one having a BIMS score of 05 and the other a score of 00. Their medical conditions included dementia, Alzheimer's disease, and other chronic health issues. The facility's logbook showed a recorded temperature of 119 degrees Fahrenheit for the same room earlier, with previous temperatures ranging from 106 to 108 degrees Fahrenheit. Despite these findings, there were no recorded injuries or grievances related to hot water temperatures in the facility's logs for the preceding months.
Failure to Develop Timely Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is required to provide effective and person-centered care. Specifically, the facility did not complete a baseline care plan addressing enhanced barrier precautions for a resident diagnosed with multiple conditions, including a urinary tract infection caused by ESBL, metabolic encephalopathy, type 2 diabetes mellitus, transient cerebral ischemic attack, chronic kidney disease stage 4, and cystitis. The resident, who had moderately cognitive impairment, was admitted over a holiday weekend, which contributed to the oversight. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the baseline care plan was not completed due to the admission occurring over a weekend. The ADON acknowledged the importance of the care plan as a guide for nurses to provide adequate care, while the DON admitted that the quick assessment during the baseline care plan process did not include consideration of the resident's ESBL and E. coli information. The facility's policy mandates the development of a baseline care plan within 48 hours of admission, but this was not adhered to in this case.
Improper Medication Storage and Access in LTC Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in a locked compartment under proper temperature controls and allowed unauthorized personnel access to medication keys, specifically affecting one resident. During an observation, a surveyor found an unidentified medicated cream in a small plastic cup on the nightstand of a resident who was cognitively intact but had some forgetfulness. The resident was admitted with diagnoses including acute kidney failure, hypertension, and skin cancer, and had specific physician orders for Betadine and Venelex for wound care, but not for zinc oxide. Interviews with the facility staff, including LVNs and the ADON, revealed that the zinc oxide cream found in the resident's room was not ordered for the resident and was not supposed to be left in the room. The wound treatment nurse and other staff members denied leaving the cream in the room, and the ADON suggested it might have been left by a weekend treatment nurse. The ADON and DON confirmed that the zinc oxide was not frequently used and was only kept in the treatment cart, with access limited to nurses. However, the zinc oxide was found in the resident's room without proper authorization or documentation. The facility's Medication Administration policy requires medications to be administered by licensed nurses or authorized staff, and any unauthorized medications found at the bedside should be reported and returned. Despite these policies, the zinc oxide cream was left in the resident's room, and the staff could not determine who was responsible. The DON emphasized that only nurses should apply zinc oxide, as it is a medication, and there should be a physician's order for its use. The incident highlights a lapse in medication management and storage protocols within the facility.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed during a survey of the kitchen. Specifically, the facility did not ensure that all food items in the refrigerators and dry storage were labeled and dated. During an initial tour of the facility's refrigerators, an opened gallon container of Dijon honey mustard salad dressing was found with two different dates on the lid, and a container of Sriracha hot chili sauce was found without a date. Additionally, six loaves of bread in the dry storage were not dated. Interviews with the Dietary Manager and staff revealed that all staff were responsible for receiving, labeling, and dating food items, and they had been trained to do so. However, the practice was not consistently followed, as evidenced by the unlabeled and undated food items found during the survey. The Consultant Dietician confirmed that monthly in-services and sanitation reviews were conducted, covering areas such as hand hygiene, safe food handling, and temperature control. Despite these measures, the staff did not consistently label and date food items, which is crucial to prevent food expiration, spoilage, or contamination. The facility's policy on food storage, revised in June 2019, mandates the use of the first-in, first-out (FIFO) rotation method and requires all refrigerated foods to be dated, labeled, and tightly sealed. The Administrator acknowledged that the Dietary Manager oversees the kitchen staff and that staff should be following the established policies.
Failure to Timely Report Resident Fall with Injury
Penalty
Summary
The facility failed to report an incident involving a resident's unwitnessed fall with injury to the State Survey Agency within the required timeframe. The incident occurred on January 4, 2024, at 7:30 a.m., when the resident sustained a 4 cm laceration to the back of her head that would not stop bleeding, necessitating a transfer to the hospital. Despite the severity of the injury, the facility did not notify the State Survey Agency within the mandated two-hour window for incidents involving serious bodily injury. The resident involved was an elderly female with a complex medical history, including Alzheimer's Disease, type 2 Diabetes Mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, heart disease, Bipolar Disorder, primary osteoarthritis, and a history of cerebral infarction. Her cognitive function was severely impaired, as indicated by a BIMS score of 01. The resident was known to be a frequent faller and had a high fall risk assessment score. Despite these known risks, the facility's care plan did not address the fall incident, and there was no documentation of interventions to prevent future falls. Interviews with facility staff revealed a lack of awareness and communication regarding the incident. Several staff members, including CNAs, nurses, and the ADON, were either unaware of the fall or did not recall the details. The ADON and Administrator acknowledged the failure to report the incident within the required timeframe, recognizing that such oversights could harm residents. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of serious incidents, which was not adhered to in this case.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to provide a resident and their representative with a written notice specifying the duration of the bed-hold policy at the time of the resident's transfer to a hospital. This deficiency was identified for a resident who was transferred to the hospital following a fall. The resident, who had severe cognitive impairment due to Alzheimer's disease, was found on the floor with injuries and was subsequently transferred to the emergency room. The facility's Bed Hold Agreement did not include necessary information such as the duration of the bed hold or the daily rate beyond the allowable days covered by the state plan. Additionally, the agreement lacked the signature of the resident's responsible party, as only verbal authorization was obtained over the phone. Interviews with facility staff revealed that the Business Office Manager (BOM) was responsible for initiating the bed hold agreement and had been obtaining only verbal consent from residents' representatives, unaware of the requirement for a written signature. The Director of Nursing (DON) and the BOM both indicated that there were no negative outcomes from the lack of a signed bed hold agreement due to the availability of rooms. However, the facility's policy required that written notice of the bed-hold policy be provided within 24 hours of an emergency transfer, and a signed copy of the notice be kept in the resident's file, which was not adhered to in this case.
Failure to Timely Report Resident Fall with Injury
Penalty
Summary
The facility failed to report an unwitnessed fall involving a resident, who sustained a 6 cm laceration to the left side of her eyebrow requiring 12 stitches, to the State Survey Agency within the required 24-hour timeframe. The incident occurred on May 10, 2024, at 5:34 p.m., but the report was not emailed until May 13, 2024. This delay in reporting could potentially place all residents at increased risk due to unreported allegations of abuse and neglect. The resident involved was an elderly female with a history of dementia, type 2 diabetes mellitus, repeated falls, and unsteadiness on her feet. Her BIMS score indicated severe cognitive impairment, which would have made it difficult for her to explain the circumstances of her fall. The resident was found on the floor with a laceration on her forehead and a skin tear on her cheek, but no loss of consciousness was noted. She was wearing non-slip socks at the time of the fall and was sent to the hospital for evaluation and treatment. Interviews with facility staff revealed that the Director of Nursing (DON) and the Administrator were responsible for reporting such incidents. The DON stated that she was notified of all falls and incidents, and the Administrator would decide whether they were reportable. However, in this case, the report was not filed within the required timeframe, indicating a lapse in the facility's adherence to its own policy on reporting alleged violations.
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report an alleged violation involving neglect within the required timeframe to the State Survey Agency. A resident, who had severe cognitive impairment and was at high risk for falls, experienced a fall resulting in a serious bodily injury, specifically a laceration to the head requiring 22 sutures/staples. The incident occurred at approximately 5 AM, but the facility did not report it to the State Survey Agency within the mandated 2-hour window for incidents involving serious bodily injury. The resident's medical history included Alzheimer's disease, anxiety disorder, bipolar disorder, osteoporosis, hypertension, insomnia, and vitamin deficiency. The resident required supervision for various activities and had a care plan in place due to her high risk for falls. Despite these precautions, the resident was found on the floor with a head injury, and the facility's staff did not immediately report the incident as required by regulations. Interviews with staff revealed that the resident was found by a CNA sitting on the floor with blood on her head. The LVN on duty assessed the resident and activated emergency services. The facility's administrator, who was responsible for reporting such incidents, delayed reporting to the state until after receiving confirmation from the hospital about the severity of the injury, which was not in compliance with the immediate reporting requirements for serious injuries.
Lack of Physician Orders for Colostomy Care at Admission
Penalty
Summary
The facility failed to have physician orders for the immediate care of a resident with a colostomy at the time of admission. This deficiency was identified for one of the four residents reviewed for physician admission orders. The resident, a male with a history of surgical aftercare following digestive system surgery and a new colostomy, was admitted without specific physician orders for colostomy care, treatment, or monitoring. Despite the presence of a care plan indicating the need for colostomy management, no orders were documented in the resident's chart from the time of admission until the deficiency was identified. The resident's hospital discharge documents did not include specific instructions for colostomy care, and the initial nursing evaluation noted the presence of a colostomy. However, the facility's records showed no physician orders for colostomy care from the date of admission. Interviews with nursing staff revealed a lack of clarity and communication regarding the responsibility for obtaining and documenting these orders. The admitting nurse, LVN A, acknowledged the oversight and indicated that the task of inputting orders was divided among staff, leading to the omission. The Director of Nursing (DON), who was newly hired, confirmed the absence of colostomy care orders and attributed it to an oversight. Despite the lack of documented orders, the DON stated that the resident was receiving colostomy care, including bag changes and monitoring, by experienced nursing staff. However, the absence of formal orders could potentially impact the resident's care. The facility did not have a specific policy for inputting physician orders for colostomy care, which contributed to the deficiency.
Incomplete Documentation of Surgical Incision
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically for a resident who had undergone surgery. The resident, a male with a history of surgical aftercare following digestive system surgery, was admitted with an abdominal incision. Despite the presence of a surgical incision, the facility's staff did not document this in the resident's skin assessment records. This omission was identified during a review of the resident's medical records and confirmed through interviews with the staff involved. The resident's care plan indicated the need for monitoring and documenting the surgical incision, yet the weekly skin evaluations completed by an LVN did not include this critical information. The LVN acknowledged the oversight, admitting that she had noted the incision in her personal journal but failed to include it in the official skin assessment documentation. The LVN recognized the importance of accurate documentation for monitoring potential changes, such as signs of infection, but did not adhere to the facility's policy requiring comprehensive documentation of all skin-related issues. The Director of Nursing (DON) confirmed the absence of documentation regarding the surgical incision and emphasized the importance of accurate skin assessments for tracking wound progress. The DON was not aware of the LVN's training history at the facility but noted that the LVN had received in-service training. The facility's policy mandates that documentation be accurate, relevant, and complete, yet this standard was not met in this instance, potentially impacting the resident's care and treatment.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically for one resident who was reviewed for medical records accuracy. The resident, a female with severe cognitive impairment and multiple diagnoses including a stage 4 pressure ulcer, had incomplete documentation in her Treatment Administration Records (TAR) for April and May 2024. The records showed unsigned sections for physician-ordered wound care on specific dates, indicating a lack of documentation for the care provided. Interviews with the nursing staff responsible for the resident's care revealed that they had completed the wound care but failed to document it in the TAR. Both LVN A and RN B admitted to not signing off on the TAR despite having performed the wound care, citing reasons such as forgetting to document or getting carried away. They acknowledged that the facility's policy required documentation of treatment provided, and their failure to do so was against the policy. The Director of Nursing (DON) confirmed the lapses in documentation and stated that the facility had not been reviewing resident charts for missed documentation during the period in question. The facility's policy on documentation required that it be completed at the time of service or no later than the shift in which the care occurred. Despite having received training on documentation, the staff did not adhere to this policy, resulting in incomplete records for the resident's wound care. The DON noted that the facility had started using an online medical records system to flag incomplete documentation, but this was not in place during the time of the deficiency.
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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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