Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Odessa Health Care Center during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies were observed in the dietary area. The convection oven, stove, refrigerators, refrigerator vents, and dry storage area had grease, debris, spills, and crumbs, and two packages of meat were being thawed in a pan of water at the sink after not being removed from the freezer the night before. The Dietary Manager and Cook A acknowledged the dirty equipment and improper thawing process.
Hand hygiene and EBP were not followed during tracheostomy/stoma care for a resident with respiratory-related diagnoses and ongoing trach site dressing needs. An RN performed the care in a common area, used gloves but no gown, and did not sanitize hands before placing a clean dressing after cleaning the stoma. In addition, TB testing records for two residents were incomplete, with missing step 2 read dates, screening, and education documentation despite step 1 being recorded.
The facility failed to provide sufficient nursing staff to meet residents’ daily care needs, resulting in repeated reports of slow call light response, unmade beds, unchanged linens, and residents not receiving their scheduled twice-weekly baths. Over several months, resident council minutes documented ongoing concerns about inadequate staffing and missed showers. A cognitively intact resident and another resident with moderate cognitive impairment, both requiring substantial assistance with bathing, each reported receiving only one bath per week and experiencing delayed call light response, especially on night shift. Staff, including CNAs, a CMT, and the Activity Director, consistently described chronic short staffing, a single bath aide assigned up to 20 showers per day, frequent pulling of the bath aide and other staff to cover basic care tasks, and the need to work early or stay late to complete duties, demonstrating that staffing levels and deployment were insufficient to carry out residents’ care plans.
A resident on hospice with anxiety, personality disorder, severe protein-calorie malnutrition, and multiple psychotropic and PRN lorazepam orders had pharmacist GDR and monthly MRR recommendations documented on pharmacy review forms, including a suggested lorazepam dose reduction and instructions to comply with CMS 14‑day limits for PRN antipsychotic-related orders. The pharmacy forms contained designated areas for the physician to indicate agreement, disagreement, or clinical contraindications to GDR and to discontinue or renew PRN orders per CMS requirements, but all physician response sections were left blank. Nursing notes and physician progress notes contained no evidence that the physician reviewed or responded to these recommendations, and the DON acknowledged that pharmacy DRR/GDR recommendations were not followed up by staff to obtain a physician response, resulting in noncompliance with the facility’s pharmacy services policy and federal requirements.
A resident who was alert and oriented and received tracheostomy care had that care performed in a common area outside the nursing station instead of in a private location. In addition, during lunch service, staff routinely prioritized room trays over residents seated in the dining room, leaving many residents waiting more than 30 minutes for meals and without beverages until dining room service began.
Failure to maintain clean vents, fans, and resident areas: heavy dust was observed in multiple shared restroom ceiling vents, a shower room vent, a resident room restroom vent, a tabletop fan in one resident’s room, and the MDR ceiling fans. Paper debris was also found under a resident’s bed on repeated observations. Staff interviews showed the Maintenance Director had not checked or cleaned the vents and fans during the time he/she had been at the facility, and a housekeeper said the paper debris was not removed because staff did not want to wake the resident.
Uncovered oxygen tubing, nasal cannulas, and face masks were found in resident rooms for three residents receiving oxygen and CPAP-related respiratory care. One resident with COPD and respiratory failure had oxygen equipment wrapped around a wheelchair and left uncovered, another resident with COPD and respiratory failure had uncovered tubing and a CPAP mask in the room, and a third resident with sleep apnea had uncovered oxygen and breathing treatment equipment left on and around the recliner. Staff said these devices were supposed to be stored in plastic bags when not in use.
Missing Staff Competency and Training Documentation: The facility failed to document annual skills and competency check-offs for CNAs and licensed nursing staff. Record review showed no evidence that staff completed required competency records, and the Administrator and DON stated there was no dedicated system to ensure the required 12 hours of training was completed. The Facility Assessment and Sufficient Staff Policy both required appropriate staff competencies and training related to resident care.
Controlled medication storage and documentation failures: The facility did not maintain accurate TAR and narcotic record documentation for Morphine and Lorazepam for multiple residents, and open bottles of these medications were found unlabeled and undated. A resident on hospice and another resident with COPD and anxiety had PRN controlled meds signed out on narcotic records without matching TAR entries, and an open Morphine bottle was found for a third resident without documentation that it had been administered. The facility also had OTC meds in a CMT cart that were past manufacturer expiration dates.
Failure to document and provide a pneumococcal vaccine for a resident with COPD and anemia. The resident signed consent after receiving education and the POS indicated the vaccine may be given, but the EHR had no record of vaccine status or administration. RN could not locate documentation and was unsure who handled vaccine documentation, while the DON said they were responsible for consent, education, administration, and documentation.
Missing COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine status, education, or refusal for five sampled residents. The DON said residents should be offered the vaccine at admission and annually, but RN A and the DON could not locate consents, education, administration records, or declination documentation in the residents' charts.
Wobbly commode safety rails were found in several shared resident restrooms and one resident room during observation with the Maintenance Director. The rails were unstable when handled, potentially affecting 15 residents. The Maintenance Director said he/she had only worked at the facility for three weeks, had not checked the rails, and did not know how often they were inspected.
A hospice resident with multiple chronic conditions, significant ADL dependence, and later bedbound status did not receive the required twice-weekly baths from facility staff as outlined in the facility’s Shower Expectations procedure, which called for two baths from facility staff in addition to two from hospice for a total of four per week. The resident’s care plan did not address bathing needs or resistance, and bath sheets over several months showed refusals and missing documentation, with all documented baths in later weeks provided only by hospice aides. Observations found the resident comfortable and without odor, while interviews with the bath aide, a CNA, and the DON confirmed that hospice residents were expected to receive four baths weekly and that facility staff were not completing their portion due to workload and staffing practices.
A facility failed to obtain written authorization from the guardian or other legal representative before withdrawing resident trust funds for specific HealthCare services for two residents. One resident had schizoaffective disorder, intellectual disabilities, and a guardian in place, while the other had Parkinson’s disease, Lewy bodies neurocognitive disorder, and severe cognitive impairment. Records showed multiple trust account withdrawals for the service, and interviews confirmed the guardian and relative were not informed or did not sign paperwork approving the deductions.
Care plan not updated for a resident with paraplegia and bipolar disorder. The resident was repeatedly observed talking loudly, yelling about religion, and making angry statements about staff and medical care, and multiple staff said these behaviors happened daily or had been constant the prior week. Although the care plan listed mood and depression problems, it did not include specific behaviors or details, and staff stated the resident’s outbursts and yelling should have been addressed in the care plan.
A resident with COPD, muscular dystrophy, malnutrition, and hospice care was placed on a LAL mattress without a documented physician order for the mattress settings or shift monitoring, and staff found the mattress powered off and deflating while the resident remained on it for over an hour. In a separate issue, a resident with TBI and other diagnoses had a smoking assessment that did not reflect documented behaviors such as hoarding cigarettes and lighters, picking up cigarette butts, and needing close supervision while smoking; staff and the DON stated the resident required supervision, but the assessment was not updated to show that need.
Incomplete catheter orders and failure to use EBP during catheter care were identified for a resident with an indwelling catheter. The resident, who was on hospice and had CKD, did not have a detailed catheter order in the chart or TAR, and staff observed emptying the catheter bag without gown and mask, with no EBP signage or PPE cart outside the room. Staff interviews confirmed the resident should have had detailed catheter orders, TAR documentation, and EBP precautions during direct care.
A resident with DM2, anemia, and a below-knee amputation had gradual weight loss while on a regular diet with Magic Cup supplements. Meal observations showed the resident ate some foods but inconsistently consumed the supplement, including one meal where staff did not remove the lid. Staff interviews showed CNAs and a CMT were unaware of weight-loss monitoring, the DON said there was no current meal intake process, and the resident's intake was not being consistently documented.
Failure to Monitor Resident Refrigerator Temperature: A cognitively intact resident reported that a personal refrigerator had been unplugged and that food inside was melted and warm, while repeated observations showed no thermometer or temperature log in the unit. Facility staff, including CNA, CMT, RN, the Activity Director, the Maintenance Director, and the DON, stated resident refrigerators should have thermometers and daily temperature checks, but none could identify who was responsible for monitoring them.
Failure to maintain hospice communication and code status orders: A resident on hospice with COPD, acute respiratory failure, cirrhosis, and oxygen use had no clear medical record documentation showing the change from Full Code to DNR. The hospice communication book was incomplete, with no code status sheet and no daily hospice summary notes, and staff stated hospice handled the books while the DON said the facility had no monitoring system to ensure they were accurate.
The facility did not maintain adequate staffing levels, resulting in residents with complex medical needs experiencing long waits for assistance, missed hygiene care, delayed medications, and late meals. Staff, including CNAs and CMTs, reported being frequently overwhelmed and unable to meet all resident needs, while non-certified personnel were directed to perform care tasks without proper training.
Facility staff did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, and failed to designate a full-time DON for several weeks. Staff interviews and review of time records confirmed the absence of RN coverage, and the Administrator could not provide documentation to verify compliance with staffing requirements.
The facility did not ensure full-time administrative oversight or required RN coverage, as the Administrator frequently acted as charge nurse due to the absence of a DON or RN for several weeks. Staff confirmed the lack of RN presence, and the Administrator could not provide documentation of RN coverage or dedicated administrative hours, potentially affecting all residents.
Three residents requiring assistance with ADLs did not consistently receive scheduled showers or baths, as documented in their care plans and facility records. Residents reported feeling unclean, experiencing body odor, and developing hygiene-related rashes, while staff and the administrator confirmed that chronic short staffing led to missed bathing opportunities and unresolved resident complaints.
Three cognitively intact residents reported receiving cold and unappetizing food, with observations confirming that meals were served at suboptimal temperatures. Staff interviews revealed that short staffing, lack of heated carts and plate covers, and delays in meal delivery contributed to the issue, with some meals prepared hours in advance and not kept warm.
Uncertified staff, including an Environmental Services worker and a dietary aide, were assigned to provide direct ADL care such as transfers, perineal care, and feeding to residents, despite lacking required certification or nurse aide training. This occurred during a shift when no certified nurse aides were present, and the Administrator confirmed noncertified staff were mandated to work to meet fire code requirements, though was unaware they were providing hands-on care.
The facility did not maintain the required minimum of three staff members on the night shift for a census of 54 residents, with only an LPN and a CNA present for several hours on consecutive nights. Staff interviews and schedule reviews confirmed the shortfall, which affected all residents and failed to meet both care and fire safety requirements.
The facility did not ensure RN coverage for at least eight hours daily and lacked a full-time onsite DON for several days, as confirmed by staffing records, staff interviews, and leadership statements. During this period, only LPNs and CNAs were present, and staff were uncertain about how to reach regional nursing support.
The facility did not post required daily nurse staffing information, including staff names, roles, hours worked, and resident census, in areas accessible to residents and visitors. Observations showed that only LPN names were listed, with no RN or DON, and no details on shift hours or census. Staff interviews confirmed that the daily staffing sheet had not been posted for weeks, and the facility could not provide recent staffing documentation or a staffing posting policy.
A CNA cultivated a relationship with a resident diagnosed with mood and affective disorders and solicited a $150 loan under the pretense of needing court cost assistance. The resident, who was cognitively intact, provided the funds but was not repaid and was unable to reach the CNA afterward. The incident was reported by the Activities Director after the resident expressed concern, and an investigation confirmed the misappropriation of the resident's money.
A resident experienced a choking incident requiring the Heimlich Maneuver, followed by new physician orders for a chest x-ray and medication changes. The responsible party was not notified of the incident or subsequent medical interventions, and staff interviews confirmed that required notifications were not completed.
The facility did not have a Registered Nurse (RN) on duty for eight hours per day, seven days a week, as required. Staffing schedules showed a lack of RN coverage on several weekends, confirmed by interviews with staff. The Director of Nursing (DON) admitted that two weekends per month lacked RN presence, affecting the care of 49 residents.
The facility failed to maintain food safety standards, as observed during a survey. A metal pan with residue, lack of a thermometer in the walk-in freezer, and chipped plate warmer covers were noted. These issues persisted during a follow-up inspection. The Dietary Manager acknowledged the need for clean food, thermometers in all cooling units, and replacement of damaged items.
The facility administration failed to manage financial obligations, resulting in unpaid debts to vendors, including utility and fire safety services. This led to potential risks for residents and staff, as essential services and supplies were jeopardized. The administrator was aware of some overdue balances but was unsure of amounts. The facility faced issues with supply orders and service disruptions due to nonpayment, including manual detergent dispensing and temporary cessation of lab services.
The facility failed to establish a comprehensive infection prevention and control program, including deficiencies in preventing Legionella and other pathogens. TB screening policies were not followed for residents and new employees, with inconsistencies in administering and reading TB skin tests. Infection control practices were not consistently followed during medication administration and wound care, with staff failing to cleanse hands and use barriers. The facility also lacked education and implementation of Enhanced Barrier Precautions (EBP).
The facility did not conduct required NA Registry checks for four new employees, missing potential Federal Indicators for abuse, neglect, or misappropriation. The Administrator was unaware of the oversight, as they were not in the position when the checks should have been completed.
The facility failed to maintain sanitary oxygen equipment for three residents, leading to deficiencies in respiratory care. A resident with a stroke was observed without oxygen during breakfast, with undated tubing and humidifier. Another resident with respiratory failure had undated equipment, and a third resident with pulmonary disease had an empty humidifier. Staff interviews revealed non-compliance with protocols for maintaining oxygen equipment, and the facility lacked an Oxygen Policy.
The facility failed to respond to the pharmacist's monthly medication regimen review for three residents, resulting in deficiencies in medication management. A resident had multiple recommendations from the pharmacist regarding cholesterol medication, missing labs, and dose reductions, but no responses were documented. Another resident's care plan lacked documentation of specific psychotropic medications, and a pharmacist's recommendation to review a Lorazepam order was not addressed. A third resident had an unclear Voltaren Gel order and was not evaluated by psychiatric services as ordered. The DON and ADON acknowledged the failure to ensure MRRs were completed and addressed.
A resident was left to self-administer medications without proper assessment or physician's order, and medication carts were found unlocked when not in use. The resident, with diagnoses including dementia and hypertension, was observed with pills on their overbed table without staff supervision. Additionally, a medication cart containing insulin was left unlocked, with residents nearby and no nurse present. Interviews confirmed that medication carts should be locked when not in use.
The facility inaccurately completed the MDS for two residents, reporting nonexistent wound infections and pressure ulcers. Staff interviews and record reviews confirmed these errors, with the MDS Coordinator acknowledging coding mistakes and a lack of direct communication with care staff.
A facility failed to complete, submit, and retain a PASRR for a resident with mental health diagnoses, including dementia and bipolar disorder, upon admission. The SSD, responsible for PASRRs, was unaware of the unavailability of records online after a year. The DON confirmed that PASRRs should be completed before admission.
The facility failed to provide two residents with baseline care plans within 48 hours of admission, as required by policy. One resident, who was cognitively intact, did not recall receiving a care plan, while another resident with cognitive impairments also did not receive one. The ADON admitted to not providing the care plans and was unclear about the responsibility, while the DON confirmed the ADON's role in this task.
A resident on hospice care with dementia and heart failure did not have a comprehensive care plan. The care plan lacked details on the resident's pressure ulcer and dementia, despite existing wound care orders. Staff interviews revealed that care plans were incomplete and behind schedule, with the ADON and social services responsible for updates.
A facility failed to follow physician's orders for a resident's blood pressure medication, administering it despite readings below specified parameters. Additionally, the facility did not obtain necessary physician's orders for another resident's colostomy care, despite the resident's recent surgery and need for specific care instructions. These deficiencies were confirmed through staff interviews and medical record reviews.
A resident was discharged to a group home without proper documentation and communication of their care needs. The facility failed to provide a recapitulation of stay, medication reconciliation, and details of the continuing care provider. Interviews with staff revealed oversights in notifying the Ombudsman and documenting follow-up care, medications, and belongings. The discharge summary was delayed, and the facility lacked a discharge policy, leading to a deficiency in ensuring a safe transition.
A resident with chronic venous hypertension and CHF experienced significant weight gain and edema due to the facility's failure to consistently apply a lymphedema compression device and monitor their condition. Despite physician notes and resident reports of inconsistent device use, the facility did not ensure proper intervention or documentation, leading to a deficiency in care.
A facility failed to provide necessary addiction recovery and psychological services for a resident needing to participate in a recovery program for a liver transplant. The resident, with a history of alcoholic cirrhosis, anxiety, and depression, was unable to attend suitable AA meetings due to the religious nature of the available option. The facility did not follow up to find alternative meetings and failed to ensure the resident received psychological services, despite physician orders. This resulted in the resident's inability to comply with liver transplant program requirements.
A facility failed to monitor antipsychotic drugs and ensure PRN psychotropic orders did not extend beyond 14 days without physician rationale for a resident with dementia, depression, and anxiety. The care plan lacked specific medication details, and behavior monitoring was incomplete. Staff interviews revealed a lack of awareness and completion of necessary monitoring tasks.
A resident with diabetes received Novolog insulin despite blood glucose levels being below the physician-ordered threshold. The facility's MAR and TAR showed multiple instances of this error. Interviews with an LPN and the DON confirmed that the nursing staff did not follow the physician's orders, and the facility lacked a policy addressing this issue.
Kitchen Sanitation and Food Thawing Deficiencies
Penalty
Summary
The facility failed to ensure kitchen equipment and food storage areas were kept clean for the storage, preparation, distribution, and serving of food. During observation, the convection oven had grease buildup on the inside windows and lip below the food racks, burnt food debris on the oven floor, and a greasy film on the outside. The stove had a greasy film and debris on the knobs, front panel, oven handle, and top platform. Refrigerator #1 had a sticky, dried orange spill on the floor with food spillage and crumbs, and Refrigerator #3 had fruits and vegetables inside with a white spillage and other food crumbs and debris on the floor. The vents on the outside of the refrigerators also had grease and debris buildup. In the dry storage room, an opened package of corn starch had white powder spilled on the floor beneath it. The report also identified improper thawing of meat at the two-compartment sink. Two packages of meat were observed thawing in a pan of water on the counter by the sink, with cold water running over them initially. During interview, Cook A stated the meat had been taken out of the freezer that morning because it had not been removed the night before, and that this was the only way to thaw it before lunch. Cook A said the meat had been in water since arrival and was almost completely thawed, but had been left in the pan when the cook went on break. The Dietary Manager observed the meat still in the pan of water and stated it should thaw under running water until ready to use. The Dietary Manager also acknowledged the oven, stove, refrigerators, and corn starch spill were dirty or improperly maintained and stated the areas should have been cleaned.
Hand Hygiene, EBP, and TB Testing Documentation Failures
Penalty
Summary
Hand hygiene and enhanced barrier precautions were not followed during tracheostomy care for one resident who had diagnoses including heart failure, hypertension, traumatic brain injury, and respiratory failure. The resident’s care plan identified risk for impaired airway clearance and respiratory compromise related to recent tracheostomy decannulation, and the resident continued to require cleansing of the tracheostomy site and dressing placement. During observation, the RN sanitized hands, put on gloves, and performed tracheostomy/stoma care in the common area outside the nursing station rather than in the resident’s room. The RN cleaned around and inside the stoma, then placed a clean dressing without degloving and washing or sanitizing hands before handling the clean dressing. The resident was not wearing a dressing over the stoma at the time of the observation. The RN stated the resident’s stoma was almost closed, that the resident was on EBP, and that PPE was available outside the room, but the RN did not wear a gown during the care because the stoma was dry and there was no bodily fluid exposure. The RN also stated the care could have been done in the resident’s room or shower room and acknowledged not sanitizing hands after cleaning the stoma before placing the dressing. The resident stated nursing staff usually completed tracheostomy care daily in the resident’s room and normally wore gloves and a gown, and did not know why the care was done in the common area that day. TB testing documentation was incomplete for two residents sampled for immunizations. For one resident, step 1 of a TB test was documented, but there was no record of the step 2 read date, screening, or education. For another resident, step 1 was documented and step 2 remained listed as pending, but there was no documentation of the step 2 read date, screening, or education. The RN stated he/she would expect a read date, time, education, and appearance to be documented, but could not find that information in either record. The DON stated there was no medical records staff at the time and confirmed that TB testing should be read within 48-72 hours, each step should be 1-3 weeks apart, and the resident record should include administered and read dates and signed education documentation.
Insufficient Nursing Staff Leading to Missed Baths and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly related to timely response to call lights and provision of scheduled baths/showers. The facility’s own Sufficient Staff Policy requires adequate numbers of licensed nurses and CNAs on a 24-hour basis, consideration of census and acuity, and ensuring staff have the competencies to carry out resident care plans. Resident council minutes over three consecutive months documented repeated resident reports that there were not enough workers, call lights were not answered promptly, beds were not being made, linens were not being changed without reminders, and residents were not receiving two showers per week as expected. One cognitively intact resident required substantial/maximal assistance with bathing and dressing and reported that staff were slow to answer call lights at all times of day and that only one bath per week was being provided instead of the two baths ordered. Another resident with moderate cognitive impairment, who required substantial/maximal assistance with bathing and supervision or touching assistance for dressing, similarly reported that night shift staff were slow to answer call lights and that only one weekly bath was being received instead of the expected two. The DON confirmed that these residents should have received two baths/showers per week and that call lights were to be answered within 10 minutes, but the residents’ statements and council minutes showed these expectations were not being met. Multiple staff interviews further demonstrated that staffing levels and assignments were insufficient to consistently complete required care. The designated bath aide reported being the only person assigned to baths/showers, with responsibility for about 20 showers per day for a 60-resident census, and stated that residents sometimes did not receive baths if the aide was pulled to help with feeding, transfers, or if residents had appointments. CNAs and a CMT reported that the facility was short staffed on all shifts, that they were unable to complete all assigned work without coming in early or staying late, and that when the bath aide was absent, floor CNAs were expected to cover baths in addition to regular duties. Staff also described delays in obtaining assistance for mechanical lift transfers and the Activity Director reported being pulled from scheduled activities to assist with direct care tasks, resulting in missed activities. These observations and interviews collectively show that the facility did not maintain sufficient nursing staff to ensure residents consistently received timely call light response and two baths per week as care-planned.
Lack of Physician Response to Pharmacist GDR and MRR Recommendations for Psychotropic/PRN Antipsychotic Use
Penalty
Summary
Surveyors identified a failure to ensure physician response to a pharmacist’s Gradual Dose Reduction (GDR) and Medication/Drug Regimen Review (MRR/DRR) recommendations for a resident receiving multiple psychotropic and PRN antipsychotic-related medications. The facility’s Pharmacy Services policy required pharmaceutical services that meet each resident’s needs and comply with state and federal requirements, including pharmacist collaboration and guidance on medication issues. Despite this, the pharmacist’s documented recommendations and regulatory reminders were not followed up with documented physician review or response as required by facility procedures. The resident involved was admitted with anxiety, a personality disorder, and hospice care for severe protein-calorie malnutrition, and had multiple psychotropic and related medications ordered, including lorazepam (scheduled and PRN), olanzapine, quetiapine, and escitalopram. A pharmacy review note dated 12/18/25 documented that the resident was receiving several psychotropic medications due for review and included a specific GDR recommendation to decrease lorazepam, along with multiple sections for the physician to indicate whether a GDR was clinically contraindicated or whether target symptoms had returned or worsened. All physician response sections on this form were left blank, and there was no documentation in nursing notes or physician progress notes indicating that the physician had reviewed or agreed/disagreed with the pharmacist’s GDR recommendations. A subsequent pharmacy review note dated 1/21/26 documented that the resident had been recently started on PRN lorazepam orders and that this was a second attempt to reduce the PRN medication. The pharmacist cited CMS regulation 483.45(e)(5) regarding the 14-day maximum duration for PRN antipsychotic orders and requested discontinuation of the current PRN antipsychotic-related orders unless specific evaluation and documentation requirements were met. The form again contained blank lines for the physician to discontinue the PRN medication or otherwise comply with CMS guidelines, but there was no documentation in the resident’s nursing notes or physician progress notes that the physician reviewed or responded to these recommendations. The physician’s monthly progress note for the resident contained no medication changes and no indication that the pharmacy recommendations or GDR had been reviewed. During interviews, the DON acknowledged responsibility for oversight of the pharmacy monthly review and confirmed that pharmacy DRR and GDR recommendations had not been followed up by nursing staff to obtain a physician response, and that the facility did not have a physician’s response documented for the resident’s GDR recommendations.
Dignity and Meal Service Delays
Penalty
Summary
The facility failed to protect a resident’s dignity and privacy during tracheostomy care. Resident #4 had diagnoses including heart failure, hypertension, traumatic brain injury, and respiratory failure, and the quarterly MDS showed the resident was alert and oriented, had no cognitive incapacity, needed moderate assistance with bathing and dressing, supervision with eating, hygiene, and transfers, used a wheelchair, and received tracheostomy care. On 2/2/26 at 9:50 A.M., the resident was observed in the common area outside the nursing station without a dressing over the tracheostomy site, and RN A performed tracheostomy care there rather than taking the resident to the room or shower room. RN A later stated the resident was usually cared for in the room and that privacy and dignity could have been maintained by moving the resident, while the DON stated tracheostomy/stoma care should not be performed in the common area. The facility also failed to treat residents with dignity during the lunch meal by delaying service to residents seated in the dining room and by not providing beverages while they waited. The lunch meal was scheduled to begin at 12:30 P.M., but on 1/28/26 dietary staff began making trays at 12:30 P.M. and nursing staff took room trays to the halls first while residents in the dining room waited. At 12:47 P.M., 22 residents were in the dining room, yet none of the meal trays had been passed out to them and no beverages had been served. The first meal tray for the dining room was not served until 1:04 P.M., and all meal trays were not served until 1:13 P.M. Interviews showed this was part of the facility’s usual meal service pattern. Dietary and nursing staff described that room trays were often prepared and delivered first, and residents in the dining room sometimes waited until after 1:00 P.M. for meals. Staff stated that beverages were not being passed to residents in the dining room until the dining room service began. The DON stated residents who came into the dining room at the designated mealtime were supposed to be served at the time of service and that it was not okay for them to wait a half hour or longer for meals or beverages.
Failure to Maintain Clean Vents, Fans, and Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing heavy dust buildup inside the ceiling vents of multiple shared restrooms serving resident room pairs 2 and 4, 1 and 3, 5 and 7, 10 and 12, 9 and 11, 13 and 15, 35 and 33, 36 and 34, 31 and 29, 32 and 30, 26 and 28, 27 and 25, and 23 and 21, as well as in a restroom for a room without a shared restroom. During observation with the Maintenance Director, heavy dust was seen inside the ceiling vents in these areas, and the Maintenance Director stated he/she had not had a chance to check the ceiling vents during the three weeks he/she had been at the facility. The report states this practice potentially affected 56 residents, with a facility census of 60 residents. The facility also failed to keep resident room [ROOM NUMBER] free of paper debris under the bed on two observations, and Housekeeper A stated the debris should have been picked up when the resident was not asleep, but it was not removed earlier because staff did not want to bump into anything and awaken the resident. In addition, a tabletop fan in Resident #49's room had a heavy buildup of dust, and Resident #49 said staff had cleaned the fan a couple of months earlier. The Main Dining Room ceiling fans also had dust buildup on the blades on two observations, and Housekeeper B said he/she had never cleaned the ceiling fans, while the Maintenance Director said he/she had not cleaned the fans during the three weeks he/she had worked at the facility and needed to make a schedule.
Uncovered Oxygen Equipment Left in Resident Rooms
Penalty
Summary
The facility failed to ensure respiratory equipment such as nasal cannulas and face masks were kept covered when not in use for three residents who were receiving oxygen therapy and were at risk for respiratory infections. The facility policy stated that delivery devices should be kept covered in plastic when not in use, but observations showed uncovered oxygen tubing, nasal cannulas, and face masks in resident rooms and on resident equipment. One resident had diagnoses including heart failure, asthma, respiratory failure, COPD, and diabetes, and was ordered continuous oxygen at 3 liters per minute via nasal cannula. During observation, the resident was seen using oxygen, with the nasal cannula in the mouth at one point and later in the nose, while the wheelchair in the room had oxygen tubing and a nasal cannula wrapped around the handles and left uncovered. The resident stated the tubing had been placed there because the nose was stopped up. The resident’s record also showed no physician’s orders for oxygen in the January 2026 POS despite the resident’s documented oxygen use. A second resident had diagnoses including heart failure, pneumonia, respiratory failure, and COPD, and had an order for oxygen at 4 liters per minute via nasal cannula continuously. When the resident was out of the room, oxygen tubing and a nasal cannula were found coiled in the recliner uncovered, and a CPAP machine behind the recliner had tubing and a face mask attached in a basket that was uncovered. The resident was later observed again with the CPAP face mask still uncovered in the basket, and the DON stated the resident routinely refused to use the CPAP machine. A third resident had diagnoses including stroke and sleep apnea, with care plan interventions for CPAP use with oxygen and an order for oxygen at 2 liters per minute at night and as needed. Observations showed the resident’s oxygen concentrator beside the bed with oxygen tubing on the floor and a breathing treatment machine with a face mask wedged between the concentrator and recliner, uncovered. Another observation showed oxygen tubing and a nasal cannula draped over the recliner armrest uncovered, and a breathing treatment machine with the face mask sitting next to it in the recliner uncovered. Staff interviews confirmed that nasal cannulas, tubing, and face masks were supposed to be stored in plastic bags when not in use, and that staff were expected to check resident rooms and replace equipment if it had fallen on the floor or become contaminated.
Missing Staff Competency and Training Documentation
Penalty
Summary
The facility failed to ensure that CNAs and licensed nursing staff had the appropriate competencies and skills check-off training completed annually and as needed to support resident safety and the highest practicable physical, mental, and psychosocial well-being. The deficiency was identified through interview and record review, and the facility census was 60 residents. Review of the facility's Sufficient Staff Policy dated 5/18/24 showed that the facility was expected to provide sufficient staff with appropriate competencies and skill sets, and that licensed nurses and nurse aides must demonstrate the competencies necessary to care for residents' needs as identified through assessments and the plan of care. Record review of annual in-services and training records dated 1/1/25 to 1/30/26 showed no documentation that staff had completed skills and competency check-off records. The Facility Assessment dated 6/29/23 stated that staff competencies necessary to provide resident care, all personnel training and competencies related to resident care, and training or competency needs based on resident and staff data or trends were to be included. During interview, the Administrator stated there was no documentation of skills and competencies check-off records, no dedicated system to ensure staff received the required 12 hours of training, and that monthly in-services and skills training for nursing staff had been discussed but not yet implemented. The DON stated staff competency was evaluated through skill checkoffs randomly and when issues came up, but there was no dedicated system to ensure staff received the required 12 hours of training.
Controlled medication storage and documentation failures
Penalty
Summary
The facility failed to ensure safe and secure storage, labeling, dating, and accountability for controlled medications, including Morphine and Lorazepam, for multiple residents. The report states that the facility did not maintain an ongoing monitoring system for narcotic medications and did not have accurate documentation on the Individual Resident Narcotic Record and TAR for doses of Morphine and Lorazepam that were signed out. The facility also failed to label and date open bottles of Morphine and Lorazepam for one resident, and failed to monitor OTC medication manufacturer expiration dates in one of the CMT medication carts. Resident #51 was admitted with diagnoses including personality disorder, muscular dystrophy, hospice care for severe protein-calorie malnutrition, and anxiety. The resident’s orders included Lorazepam concentrate 2 mg/ml every one hour as needed for agitation and Morphine sulfate concentrate oral solution every one hour as needed for pain or shortness of air. Review of the TAR and Individual Resident Narcotic Record showed multiple instances where Lorazepam and Morphine were signed out on the narcotic record but not documented as given on the TAR. The report also noted a handwritten change to the Morphine dose on the narcotic record without identification of who made the note. During observation, the resident’s open bottles of Lorazepam and Morphine were found in storage without the resident’s name on the bottle and without a date showing when they were opened. Resident #10 was on hospice services with diagnoses of COPD and anxiety, and had orders for Lorazepam concentrate and Morphine sulfate concentrate as needed for agitation/anxiety and pain/air hunger. The TAR showed no documentation that Lorazepam or Morphine were given during the reviewed period, while the handwritten narcotic record showed the medications were signed out. Resident #35 had COPD and anxiety, and the Individual Resident Narcotic Record showed an open bottle of Morphine with no documentation that the medication had been signed out; the DON stated the bottle had been opened even though there was no documentation that it had been administered. In addition, observation of the CMT medication cart showed OTC medications, including Vitamin C, Allergy Relief, and a multivitamin, were still being used past their manufacturer expiration dates, and the CMT stated these expired OTC medications should not have been in the cart or used.
Failure to Document and Provide Pneumococcal Immunization
Penalty
Summary
The facility failed to maintain its infection prevention and control program when it did not provide a pneumococcal vaccine for one sampled resident out of five reviewed for immunizations. The facility’s policy stated that residents or their legal representatives were to receive education on influenza and pneumococcal immunizations, sign a revolving consent form, and be offered the pneumococcal vaccine upon admission unless medically contraindicated, already documented as received, or refused. The report also noted that no revolving consent was provided. Resident #46 had diagnoses including COPD and anemia. The resident’s physician order sheet indicated the pneumococcal vaccine may be given, and an annual immunization consent form showed the resident was educated on the risks, benefits, and side effects and agreed to receive the pneumococcal immunization. However, the EHR immunization record contained no documentation of pneumococcal vaccine status. RN A stated they could not locate documentation of the vaccine in the EHR and were unsure who was responsible for administering and documenting vaccine information. The DON stated residents who received education and signed consent should have received the vaccination, but no documentation of administration could be found, and the DON said they were responsible for obtaining consent, education, administration, and documentation.
Missing COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to maintain its infection prevention and control program when it did not ensure that five sampled residents were offered COVID-19 vaccination and that documentation existed showing vaccine education or refusal. The facility's Infection Prevention and Control Program stated that residents would be offered the COVID-19 vaccine when available, that education about risks, benefits, and side effects would be provided before offering the vaccine, and that documentation would reflect the education provided and whether the resident received the vaccine. However, review of the medical records for Residents #2, #10, #35, #46, and #51 showed no documentation of COVID-19 vaccine status or that education regarding the risks and benefits of the vaccine had been provided since admission. During interviews, the DON stated that COVID vaccines should be offered and education given at admission and annually, and later said residents who were offered the vaccine should receive an education/declination form, although no such form was currently in use. RN A stated that immunization information would be expected in the immunization tab and was unable to find documentation of consents, education, or administration of the COVID vaccine for the five residents in the chart, progress notes, forms, or uploaded documents. The DON later stated he/she was responsible for explaining and obtaining the information, completing a consent/declination form, and uploading it into the resident's medical record, but was unable to locate documentation of education, administration, or declination for the five residents.
Wobbly Commode Safety Rails in Multiple Resident Restrooms
Penalty
Summary
The facility failed to ensure that commode safety rails in multiple shared restrooms and one resident room were sturdy. During observation with the Maintenance Director, the commode safety rails in the shared restrooms of resident rooms [ROOM NUMBERS], [ROOM NUMBERS], [ROOM NUMBERS], [ROOM NUMBERS], and in resident room [ROOM NUMBER] were wobbly when handled. The report states this potentially affected 15 residents who lived in those rooms, and the facility census was 60 residents. During interview, the Maintenance Director said he/she had only been at the facility for three weeks, had not had a chance to check the commode safety rails, and did not know how often they were checked.
Failure to Provide Required Twice-Weekly Facility Baths for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a hospice resident received the required number of baths per the facility’s own Shower Expectations procedure. That procedure required that residents on hospice be offered two showers per week from facility staff in addition to two baths from hospice staff, for a total of four baths weekly. The procedure also required that bed baths be limited and approved, that all shower declines be immediately reported to the charge nurse and, if ongoing, to the DON or Administrator, and that all showers and refusals be documented and signed on shower sheets. For the sampled hospice resident, the care plan did not address the resident’s bathing capabilities, level of assistance needed for bathing, or any resistance to bathing, despite documenting extensive assistance needs for other ADLs. The resident had multiple diagnoses including heart failure, hypertension, diabetes, hyperlipidemia, GERD, arthritis, stroke, traumatic brain injury, anxiety, and depression, and was alert with minimal cognitive impairment. The MDS showed the resident required maximum assistance with bathing, dressing, toileting, hygiene, and transfers, used a wheelchair, and was receiving hospice care. Later hospice documentation indicated the resident became bedbound, required at least 40% assistance with ADLs, no longer got out of bed, used a full-body mechanical lift, had increased confusion, poor appetite, and required oxygen. Hospice notes stated that the hospice bath aide visited daily to complete care, bathing, and feeding/drinking assistance. Review of bath sheets showed that in November one bath was refused and another scheduled bath had no documentation of being offered or given. In December, one bath was refused and multiple baths were documented as completed by hospice staff, with no evidence that facility staff provided their required baths. In January, all documented baths were completed by the hospice aide, with no documentation that facility nursing staff or the bath aide provided any baths, and the resident did not receive the minimum number of baths required by facility policy. Observations on two separate days showed the resident in bed, dressed appropriately, on oxygen, resting comfortably, and without odor. Interviews with the bath aide, a CNA, and the DON confirmed that hospice residents were expected to receive four baths weekly (two from hospice and two from facility staff), that the bath aide prioritized non-hospice residents due to workload, that CNAs and nursing staff were supposed to assist with baths when the bath aide could not complete them, and that the baths facility staff were supposed to provide to hospice residents were not being completed.
Resident trust withdrawals made without written guardian authorization
Penalty
Summary
The facility failed to obtain written authorization from the guardian of two residents before making withdrawals from their Resident Trust accounts for specific HealthCare services. The facility policy titled Resident Trust stated that personal funds of the resident must be used exclusively for the resident and must be authorized in writing by the resident, legal guardian, or legal representative. Review of the resident trust records showed withdrawals made for specific HealthCare payments for two sampled residents without signed authorization from the guardian or other authorized representative. One resident had schizoaffective disorder, intellectual disabilities, primary insomnia, and hypertension, and the medical record showed a guardian had been in place since July 2011. The resident’s trust transaction history showed two withdrawals for specific HealthCare payments, but there was no signed authorization from the guardian. During a phone interview, the guardian stated he or she had not been informed about the resident signing up for specific HealthCare, did not know what it was, would have wanted to explore it further, and had not been asked to approve enrollment. The second resident had Parkinson’s disease, Lewy bodies neurocognitive disorder, restless legs syndrome, and severe cognitive impairment. The resident trust summary showed multiple withdrawals for specific HealthCare payments, but the relative stated no paperwork or forms were signed to allow money to be withdrawn from the resident’s trust account. The Business Office Manager and Social Service Designee stated the residents were already enrolled or had been asked to sign up for specific HealthCare, but neither identified written consent from the guardian or representative for these two residents.
Care Plan Not Updated for Resident’s Mood and Behavioral Needs
Penalty
Summary
The facility failed to ensure the mood and behaviors section of the care plan was up to date for one resident with paraplegia, bipolar disorder, and hypertension. The facility’s policy stated that comprehensive care plans were to be developed for each resident, reviewed and revised by the interdisciplinary team after comprehensive and quarterly MDS assessments, and include measurable objectives and time frames to meet identified needs. The resident’s care plan dated January 2026 listed mood and depression problems, but the entries were vague and did not include specific behaviors or details about the resident’s indicators. The resident’s quarterly MDS dated 1/1/26 showed the resident was cognitively intact and had bipolar disorder, paraplegia, and hypertension. During multiple observations, the resident was seen talking loudly, laughing, and speaking at the television during bible study, and later was observed in a motorized wheelchair speaking loudly with an angry, sarcastic tone about the facility charging money and calling medical staff quacks. The resident also told staff that medical facilities did not know what they were doing, that doctors and pharmacists were liars and greedy, that staff were keeping the resident alive and playing God, and that the resident’s roommate was not a Christian. Staff interviews confirmed the resident’s loud, religiously focused, and argumentative behavior was occurring frequently, with several staff stating it happened daily or had been constant the prior week. Multiple staff members said the resident’s behaviors should have been addressed in the care plan, including how to work with the resident and how to help manage the behaviors. The RN described the resident as very opinionated and loud, especially when in the motorized wheelchair, and the DON stated there should be something in the care plan about the resident’s outbursts and yelling behaviors, while also acknowledging responsibility for keeping care plans up to date.
Missing LAL Mattress Order and Inaccurate Smoking Safety Assessment
Penalty
Summary
The facility failed to obtain and transcribe a physician order for a Low Air Loss mattress with soft side bolsters for a resident with multiple diagnoses, including muscular dystrophy, COPD, severe protein-calorie malnutrition, anxiety, personality disorder, and hospice care. The resident’s care plan did not include the use or monitoring of the mattress, and the physician order sheet and treatment administration record did not contain an order for the mattress settings or for shift-by-shift monitoring of inflation and function. During observation, the resident was found on the LAL mattress with the power box not turned on and the mattress deflating, and the resident remained on a partially deflated mattress for over one hour before the mattress was turned back on and inflated. Interviews showed staff were unsure of the protocol for LAL mattress use and monitoring. A CNA stated the mattress should be working when the green and red lights were on and that licensed staff were responsible for documenting monitoring every shift. A CMT stated the mattress settings and function should be checked every shift and that the order should be on the TAR. An RN stated he or she was unsure of the facility protocol and whether a physician order was required. The DON stated the resident’s LAL mattress should have had a physician order on the POS including settings and monitoring every shift, that licensed staff were responsible for documenting the monitoring on the TAR, and that all care staff were responsible for observing the mattress and power box to ensure the bed was turned on. The facility also failed to ensure the smoking assessment accurately reflected the current safety status of a resident with heart failure, hypertension, traumatic brain injury, and respiratory failure who had documented smoking-related behaviors. The resident’s care plan identified noncompliance with smoking rules, including hoarding cigarettes and lighters and attempting to leave the building to smoke outside designated times and areas. However, the smoking and safety assessment did not document concerns or the need for supervision, and it did not show the resident was safe to smoke. Nursing documentation showed the resident had been observed picking up cigarette butts, pocketing cigarettes, and refusing to give staff a lighter. The record also showed no reassessment after these behaviors were noted and no documentation of ongoing monitoring or re-education in the resident’s chart during the reviewed period. Observations and interviews confirmed the resident continued to smoke on the patio with staff supervision, while staff passed out cigarettes and lit them for residents. Staff stated the resident had a history of hoarding cigarettes and lighters, smoking cigarette butts, and needing close supervision while on the smoking patio. The RN and DON both stated the resident absolutely needed to be supervised while smoking because of these behaviors and that the smoking assessment should have been reassessed when the behaviors began. The DON also stated the resident had past behaviors of dumping the smoking receptacle and smoking cigarette butts, and that the nursing staff had to watch the resident all of the time because of these behaviors.
Incomplete Catheter Orders and Failure to Use EBP During Catheter Care
Penalty
Summary
The facility failed to obtain and transcribe a detailed physician order for a resident with an indwelling catheter. The resident was admitted to hospice services and had a diagnosis of chronic kidney disease. The quarterly MDS showed the resident was cognitively intact, able to understand others and make needs known, and required staff assistance for all cares. The physician order sheet and TAR did not include a detailed catheter order identifying the type of catheter, the French size, the balloon size, or the frequency and method of catheter care and monitoring. During observation, the resident’s catheter drainage bag was hooked to the bed frame and covered by the privacy flap. A CNA stated that he/she only emptied the catheter bag and that licensed nursing staff were responsible for catheter care. When catheter care was observed, the resident did not have EBP signage posted on the door and there was no isolation cart with PPE outside the room. CNA B sanitized hands, put on gloves, obtained a barrier and graduate, and emptied the drainage bag without wearing a gown or mask. The CNA cleaned the drainage spout with an alcohol wipe, emptied the graduate, rinsed it with water, removed gloves, and left the room. On a later observation, CNA B entered the resident’s room without EBP. During interview, a CMT stated he/she was not aware the resident should have been on EBP and was not familiar with the facility protocol for residents on EBP. An RN stated the resident should have had a detailed catheter order, catheter care documented in the TAR, and EBP signage with an isolation cart outside the room; the RN also stated staff providing direct contact care for residents on EBP should wear gown and gloves. The DON stated nursing staff were responsible for obtaining a detailed catheter order, transcribing it to the TAR, documenting catheter care and monitoring, and expected staff providing catheter care to wear PPE.
Failure to Monitor Meal Intake for Resident With Weight Loss
Penalty
Summary
The facility failed to ensure that a resident's meal intake was monitored when the resident had gradual weight loss. The resident had diagnoses including type 2 diabetes mellitus without complications, iron deficiency anemia, and acquired absence of the right leg below the knee. The annual MDS showed the resident was moderately cognitively impaired, dependent on staff for self-care, used a wheelchair, needed supervision or touching assistance with eating, and was unable to walk. The physician orders included a regular diet with thin liquids and Magic Cup with every meal related to diabetes. The resident's weight record showed a decline from 118.1 lbs in November to 110.4 lbs in December and 108.0 lbs in January, including a 3% loss in one month and an 8% loss over two months. Observations during three meals showed the resident ate portions of the meals but did not consistently consume the Magic Cup supplement; on one occasion the lid was not removed and staff did not remove it, and on later observations the resident ate only about one-quarter of the Magic Cup. The care plan stated the dietary department would monitor the resident's diet monthly and the dietician would review the chart quarterly. Staff interviews showed inconsistent awareness and monitoring of the resident's weight loss and meal intake. A CNA and a CMT stated they had not heard that anyone needed to be monitored for weight loss, and the CMT did not know if anyone monitored meal intakes. The Dietary Manager stated the CNAs monitored meal intake and that the resident had lost a couple pounds, while an RN stated CNAs should document meal percentages and that the resident should be weighed weekly if losing weight. The DON stated there was currently not a meal intake process and that the CNAs were supposed to notify the charge nurse if a resident did not eat, but the meal intake book was no longer used.
Failure to Monitor Resident Refrigerator Temperature
Penalty
Summary
The facility failed to ensure that a resident’s personal refrigerator had a thermometer and that the temperature was monitored and logged. The facility policy stated that resident personal refrigerators and facility snack refrigerators were to be monitored daily, kept within 32-40 degrees, have a thermometer in both the freezer and refrigerated compartments, and have a daily temperature log. For one cognitively intact resident, review of the quarterly MDS showed the resident was cognitively intact, and the resident reported that the refrigerator had been moved and unplugged while staff were assisting the roommate early in the morning. The resident stated there had never been a thermometer or temperature log since receiving the refrigerator in December 2025 and reported finding sherbet in the freezer and meat and cheese in the refrigerator that were melted and warm. Observations on multiple dates showed there was no thermometer or temperature log with the refrigerator. During interviews, several staff members stated they did not unplug resident refrigerators and were unsure who was responsible for monitoring them. CNA A, CMT A, the Activity Director, RN A, and the DON all stated that resident refrigerators were supposed to have thermometers and be checked daily, but none could identify who was responsible for keeping track of the temperatures. The Maintenance Director and Housekeeper A also stated they had no knowledge of monitoring resident refrigerator temperatures.
Failure to Maintain Hospice Communication and Code Status Orders
Penalty
Summary
The facility failed to ensure communication was established and completed between the facility and hospice nursing staff, and failed to ensure change-of-condition hospice orders were in place for one resident who was receiving hospice services. The cited policy stated the facility would coordinate care with hospice, maintain written agreements for communication, communicate and document interventions, monitor the resident’s response to hospice care, and immediately contact hospice staff and the attending practitioner regarding significant changes in status. Resident #59 had diagnoses including COPD, acute respiratory failure with hypoxia, unspecified cirrhosis of the liver, dehydration, muscle weakness, and need for assistance with personal care. The resident’s MDS showed the resident was moderately cognitively impaired, on hospice, on oxygen, used a wheelchair, and needed assistance with activities of daily living. The physician orders included hospice to evaluate and treat as indicated, but there were no notes showing the resident changed from Full Code to DNR after admitting to hospice. The resident’s DNR form was signed by the resident and attending physician, but the hospice communication book had another name on the STOP page at the start of the book, no code status sheet, and no summary notes from hospice staff from daily visits. During interview, RN A stated residents should have hospice and code status orders in the medical record, hospice personnel took care of the hospice books, and hospice personnel would tell the nurse if there were any new orders or changes. RN A also stated he or she did not do anything with the hospice books. The DON stated there should be orders for a resident on hospice with a DNR, Social Services was supposed to audit the hospice books, nurses were to make sure orders were placed in the medical record, and the facility did not have a monitoring system to ensure the hospice books were up to date and accurate.
Failure to Maintain Sufficient Staffing to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the basic needs and ensure the safety of all residents, as evidenced by staff schedules, time punches, and multiple interviews. On several nights, staffing levels fell below the facility's own minimum requirements, with as few as one or two staff members present for 56 residents during overnight shifts. There were instances where only non-certified staff or a single CNA was present, and on some nights, the only staff in the building were not certified to provide direct resident care. The written schedules often did not match the actual staff present, and non-certified staff were instructed to perform resident care tasks for which they had not been trained. Residents with significant care needs, including those with Parkinson's Disease, a history of falls, rheumatoid arthritis, spinal stenosis, and cognitive communication deficits, reported long waits for call lights to be answered, missed or delayed baths, and delays in receiving medications and meals. Residents described waiting 30-45 minutes or longer for assistance, not receiving regular hygiene care, and experiencing late or cold meals due to insufficient staff to distribute trays. Staff interviews corroborated these accounts, with CNAs and CMTs reporting that they were frequently the only caregivers on the floor, leading to delays in care, missed medications, and residents not being laid down or changed in a timely manner. Non-certified staff, including housekeepers and environmental services personnel, were directed to assist with resident care tasks such as transferring and feeding residents, despite lacking proper training or certification. Staff described being overwhelmed, unable to complete all required tasks, and sometimes having to perform two-person transfers alone. Observations confirmed that many residents remained in bed past scheduled times for breakfast, and soiled linens were noted by laundry staff. The administrator acknowledged the staffing shortages and stated that he or she had to cover shifts as a charge nurse and come in at night when no nurse was available.
Failure to Provide Required RN Coverage and Designate Full-Time DON
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, and did not designate a Director of Nursing (DON) on a full-time basis, as required by facility policy and federal regulations. Review of facility records, including the Facility Assessment Tool and daily punch records, showed that the facility had been without RN coverage for approximately three weeks prior to the new DON starting. Multiple staff interviews confirmed the absence of RN coverage during this period, with both LPN and CNA staff stating they had not observed an RN in the building. The Administrator was unable to provide proof of RN coverage and acknowledged that the previous DON had left some time ago, with the new DON only starting recently. Payroll and time records further substantiated the lack of RN presence, with no RN clock-ins documented on multiple days and shifts over several weeks. The facility's own policy required RN coverage for at least eight consecutive hours daily and a full-time DON, but these requirements were not met. The Administrator also failed to provide the requested Payroll Based Journal (PBJ) documentation to verify RN staffing. The deficiency was identified during a complaint investigation with a facility census of 56 residents.
Failure to Provide Full-Time Administrative and RN Coverage
Penalty
Summary
The facility failed to provide administrative oversight and required RN coverage, resulting in a lack of full-time administration and nursing supervision for an extended period. The facility was without a Director of Nursing (DON) or RN coverage for approximately three weeks, during which time the Administrator frequently assumed the role of charge nurse for both day and night shifts. Interviews with staff, including LPNs and CNAs, confirmed that there was no RN present in the building during this period, and the Administrator was often observed performing multiple roles, including charge nurse, social worker, and Administrator. The facility's own policies required RN coverage for at least 8 consecutive hours per day, 7 days a week, and designated a full-time DON, but these requirements were not met. Review of the facility's daily schedules and staff interviews corroborated that the Administrator regularly covered nursing shifts due to the absence of RNs, and there was no documentation to prove that RN coverage was provided as required. The Administrator was unable to provide proof of RN coverage or evidence of dedicating 40 hours per week to administrative duties. Additionally, a Payroll Based Journal (PBJ) was requested by the surveyor but was not provided. The lack of administrative and RN presence had the potential to affect all 56 residents in the facility.
Failure to Provide Scheduled Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining grooming and personal hygiene, for three residents who required varying levels of support with bathing. Facility records and interviews revealed that these residents, all cognitively intact and with documented physical limitations such as Parkinson's disease, impaired balance, and muscle weakness, did not consistently receive showers or baths as outlined in their care plans. Documentation showed multiple missed opportunities for scheduled showers over several weeks, with some residents missing up to six out of nine scheduled showers in a month. Residents reported not receiving the required twice-weekly showers, despite requesting assistance from staff. They described feeling unclean, experiencing embarrassment due to body odor, and, in one case, developing yeast rashes attributed to inadequate hygiene. Staff interviews confirmed that residents were not being bathed as required, citing chronic short staffing as the primary reason. CNAs and LPNs acknowledged that some residents went weeks without bathing, and that complaints from residents about missed showers were ongoing and unresolved. The facility's own policies required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, and that showers be provided according to resident needs and facility protocols. However, both staff and the facility administrator confirmed that there were no assigned staff to ensure residents received their scheduled baths or showers, resulting in unmet care needs and repeated resident complaints. The Ombudsman also reported receiving numerous complaints regarding lack of bathing at the facility.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature to three out of four sampled residents, all of whom were cognitively intact. Multiple residents reported receiving cold and unappetizing food, with some stating that the temperature of the food influenced their willingness to eat. Observations confirmed that food items such as beef stroganoff, steamed broccoli, mashed potatoes, and hamburgers were served at temperatures below what is generally considered safe and appetizing. Additionally, pudding was served at a temperature of 67.3 degrees F. The facility was unable to provide its Food Temperature policy when requested. Interviews with staff revealed systemic issues contributing to the deficiency, including chronic short staffing, delays in meal delivery, and insufficient equipment such as plate covers and heated carts. Dietary staff reported that meal trays often waited up to 30 minutes before being picked up for delivery, and that not all trays could be covered or kept warm. Some meals were prepared up to three hours in advance and left sitting out until mealtime. Staff also noted that steam tables were not consistently used to keep food warm, and disciplinary actions had been taken against some kitchen staff for improper meal preparation and service.
Uncertified Staff Provided Direct Resident Care
Penalty
Summary
The facility failed to ensure that only certified or trained personnel provided Activities of Daily Living (ADL) care to residents, as required by state law and facility policy. On a specific evening/night shift, an Environmental Services staff member, who was not certified and had never received nurse aide training, was instructed by the previous DON to assist with resident cares, including transfers, changing briefs, perineal care, and feeding. This staff member reported feeling uncomfortable performing these tasks but did so to avoid leaving residents in need. Review of staffing records confirmed that there were no certified nurse aides on the floor during this shift, despite a census of 56 residents, many of whom required assistance with ADLs. Additionally, a dietary aide under the age of 18, hired to assist with food service, was placed on a mandatory staffing calendar to meet fire code requirements and worked overnight shifts, during which they passed ice and answered call lights. The dietary aide's job description did not include resident care duties, and their qualifications did not meet the requirements for providing hands-on care. The Administrator acknowledged mandating noncertified staff to work night shifts to meet fire code regulations but was not aware that these staff were instructed to provide direct resident care. Employee files and job descriptions reviewed did not show evidence of appropriate training or certification for resident care among the noncertified staff involved.
Failure to Maintain Minimum Night Shift Staffing Levels
Penalty
Summary
The facility failed to provide sufficient staffing on a 24-hour basis to meet the needs of all residents and to comply with minimum staffing requirements for fire safety. According to the facility's own policy, with a census of 54 residents, at least three staff members were required on the night shift. However, review of staff time punches and schedules for two consecutive nights showed that only two staff members, an LPN and a CNA, were present in the building for significant portions of the night shift, specifically from approximately 11:00 P.M. to 4:00 A.M. There was no third staff member present during these hours, and this was confirmed by staff interviews and schedule reviews. Additional staff, such as a CMT or another CNA, were only present for part of the evening and left before the required night shift coverage was met. Interviews with facility staff, including the LPN, CNA, Social Services Designee, and Interim DON, confirmed awareness of the staffing shortfall and that the required number of staff was not maintained during the night shift. The Regional CNO was not aware of the deficiency until it was reported during a call. The deficiency affected all 54 residents in the facility, as the lack of adequate staffing could impact both resident care and fire safety compliance. No specific residents were identified as being directly harmed in the report, but the deficiency was systemic and ongoing over at least two consecutive nights.
Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) on duty for at least eight hours per day, seven days per week, and did not have a Director of Nursing (DON) or interim DON onsite full-time for a minimum of 40 hours per week. Review of staffing records and facility assessment revealed that there was no RN or DON coverage on multiple days, specifically on 4/7/25 and 4/8/25, despite a census of 54 residents. Observations confirmed that only LPNs and CNAs were present during these times, with no RN or DON listed on posted staff rosters. The facility's staffing policy for RN and DON requirements was requested but not provided. Interviews with staff and regional leadership confirmed that the DON had resigned without notice, and there was no RN coverage on the days in question. Staff reported uncertainty about RN or DON presence and lacked contact information for regional nursing support. The interim DON arrived only after the period of non-compliance, and regional and corporate leaders acknowledged gaps in RN coverage and the absence of an acting DON onsite during the deficiency period. No residents requiring RN-specific care were identified at the time, but the required RN and DON coverage was not maintained as per regulatory requirements.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was easily accessible to residents and visitors. Observations revealed that the required staffing data, including the facility name, daily census, and actual hours worked per shift for RNs, LPNs, and CNAs/CMTs, was not posted in public areas such as the nursing station or lobby. The posted list only included the names of four LPNs, with no RNs or Director of Nursing (DON) listed, and did not display the number of staff scheduled or the hours worked for each shift. At the time of observation, the facility had one LPN and two CNAs on duty for a census of 54 residents, with no RN present in the building. Interviews with staff indicated that the daily staff sheet had not been visibly posted for several weeks or months, and the previous practice of handwriting staffing information on a whiteboard had ceased. The interim DON confirmed the expectation that daily staffing ratios should be posted in public view. When requested, the facility was unable to provide documentation of daily staffing ratios for the previous days or weeks, and the facility's staffing posting policy was not provided upon request.
CNA Solicits and Fails to Repay Loan from Resident, Resulting in Misappropriation
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) developed a personal relationship with a resident and solicited a loan of $150.00 from the resident. The CNA explained to the resident that the money was needed to pay court costs, and the resident, who was cognitively intact but had a history of mood and affective disorders, provided the funds. The resident later attempted to contact the CNA for repayment but received no response. The incident came to light when the resident expressed concern to the Activities Director about not being repaid, stating that it took a long time to save that amount of money given their limited monthly income. The Activities Director immediately reported the situation to the facility Administrator, who initiated an investigation. Statements were collected from the resident and staff, and the police were notified, although law enforcement indicated they could not take action since the money was given as a loan. The CNA in question had already been terminated for unrelated attendance issues prior to the discovery of the misappropriation. The facility's review of the incident confirmed that the CNA had borrowed money from the resident, which constituted misappropriation and exploitation as defined by the facility's abuse and neglect policy. The resident was left without the funds until the facility intervened.
Failure to Notify Responsible Party After Resident Choking Incident and Medical Changes
Penalty
Summary
Facility staff failed to notify a resident's responsible party after a significant change in condition occurred, specifically when the resident experienced a choking incident during supper. The resident, who was cognitively intact and independent with meals, had no prior signs or symptoms of swallowing issues. During the incident, the resident became blue/purple in color, was unable to speak or move air, and required the Heimlich Maneuver and back thrusts to dislodge the obstruction. Following the event, the physician ordered a chest x-ray, which indicated possible bronchitis or pneumonia, and made changes to the resident's medication regimen, including doubling Torsemide and starting azithromycin. Despite these significant changes and interventions, there was no documentation that the resident's representative was notified of the choking incident, the new physician orders, or the medication changes. The responsible party only became aware of the incident after being informed by the resident's spouse. Interviews with staff, including an LPN and the DON, confirmed that the charge nurse was responsible for such notifications but failed to do so in this case.
Failure to Ensure RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were utilized for eight hours per day, seven days a week, as required by their policy. A review of the facility's daily staffing schedules from March 1, 2024, to May 24, 2024, revealed that there was no RN on duty on several Saturdays and Sundays during this period. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Staffing Coordinator, confirmed that RNs were not scheduled on weekends, and the facility had been unable to schedule RNs for weekend shifts for some time. The Director of Nursing (DON) acknowledged that the facility employed only two RNs, including themselves, and admitted that there were two weekends per month when no RN was present for the required eight consecutive hours. The DON stated that staff were aware they could contact them with any issues when no RN was on duty. This deficiency had the potential to affect all 49 residents of the facility, as the absence of an RN on weekends could impact the quality of care provided.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to maintain proper food safety standards as observed during a survey. During an initial kitchen inspection, a blue-handled metal pan was found on the bottom shelf of a metal pot/pan rack with heavy black residue on the inside rim. Additionally, the walk-in freezer lacked a thermometer, which is necessary to confirm adequate temperature ranges. Three maroon plate warmer covers with chipped edges were found in a dishwasher rack, ready for use, posing a risk of cross-contamination. A test lunch plate was observed covered with a chipped blue plate warmer lid, further indicating a lack of adherence to food safety protocols. A follow-up inspection revealed that the issues had not been addressed, as the blue-handled metal pan with residue remained on the storage rack, and the walk-in freezer still lacked a thermometer. Another test lunch plate was covered with a heavily chipped maroon plate warmer lid. During an interview, the Dietary Manager acknowledged that food should be free of foreign substances, all refrigerators and freezers should have thermometers, and damaged kitchen items should be discarded and replaced. These deficiencies had the potential to affect all residents, visitors, volunteers, and staff consuming food from the kitchen.
Facility Administration Fails to Manage Financial Obligations, Jeopardizing Services
Penalty
Summary
The facility administration failed to manage its financial obligations effectively, resulting in unpaid debts to various vendors, including utility and fire safety services. This failure to pay debts led to potential risks for residents and staff, as essential services and supplies were jeopardized. The facility's administrator did not have a policy outlining their duties, and there was no policy regarding the payment of vendors. The administrator, who had been at the facility for only a couple of months, was aware of some overdue balances but was unsure of the amounts and unaware of any service stoppages. The facility had significant past due amounts with several vendors, including an imaging vendor, food vendor, respiratory supply vendor, utility supplier, fire sprinkler vendor, and a chemical supply company. Payments for some of these debts were made only after surveyors began their annual survey. The chemical supply company had placed the corporate account on credit hold due to nonpayment, leading to the removal of laundry pumps and the cessation of services. This resulted in laundry staff manually dispensing detergent without proper instructions, as they were unsure of the correct amounts to use. Interviews with staff revealed that the facility had faced issues with supply orders and service disruptions due to nonpayment. The laundry staff struggled with manual detergent dispensing, and the laboratory company had temporarily stopped providing services, requiring residents to be sent to the hospital for lab draws. Additionally, there were instances where trash was not picked up due to unpaid bills. The Director of Nursing confirmed that the facility was behind on paying bills, and the administrator was responsible for sending bills to the corporate office, which was behind on payments.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, which included deficiencies in preventing the development and transmission of Legionella and other water-borne pathogens. The facility lacked a documented risk management plan assessment and infection prevention program to address potential outbreaks. Additionally, there were no facility-specific testing protocols or public water utility reports on chemicals in the water, and the Maintenance Supervisor and Administrator had limited education on Legionella program requirements. The facility also failed to properly screen and follow tuberculosis (TB) policies for residents and new employees. Several residents did not have their TB skin tests (TST) administered or read according to the facility's policy, and there were inconsistencies in the documentation of TSTs. Similarly, new employees did not receive their TSTs in a timely manner, with some tests being administered or read late, and others not receiving a second TST as required. Infection control practices were not consistently followed during medication administration and wound care. Staff failed to cleanse their hands between administering medications, did not use barriers for wound care supplies, and did not follow Enhanced Barrier Precautions (EBP) guidelines. Additionally, there were issues with the handling of intravenous lines and wound VACs, with equipment being placed on unclean surfaces without proper barriers. The facility also lacked education and implementation of EBP, with staff unaware of the guidelines and their importance in infection prevention.
Failure to Conduct NA Registry Checks
Penalty
Summary
The facility failed to include a policy to check the Nurses' Aide (NA) Registry for Federal Indicators, which are markers for abuse, neglect, or misappropriation of property, for all employees prior to hire. This deficiency was identified during a review of the facility's hiring practices, where it was found that the NA Registry checks were not completed for four out of ten sampled new employees. The employees in question were hired between February and March 2024, and their files lacked documentation of the required NA Registry checks. During an interview, the Administrator acknowledged the oversight, stating that they were not in the position when the checks should have been completed and were unaware that some background checks did not include the NA Registry check.
Deficiency in Maintaining Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment in a sanitary condition for three residents, leading to deficiencies in respiratory care. Resident #9, who was cognitively intact and on continuous oxygen therapy due to a stroke, was observed eating breakfast without oxygen. The oxygen tubing was improperly stored, with no date indicating when it was last changed, and the humidifier lacked a date as well. Resident #41, with acute respiratory failure and an upper respiratory infection, had oxygen orders that were not reflected in the care plan. Observations showed the oxygen tubing was left on the bed while running, and both the tubing and humidifier were undated. Resident #5, with pulmonary disease and moderate cognitive impairment, was found with undated oxygen tubing and an empty humidifier. Interviews with staff revealed a lack of adherence to protocols for maintaining oxygen equipment. Certified Medication Technician A and Licensed Practical Nurse A confirmed that oxygen tubing should be stored in a bag with the date of change written on it, and the humidifier should be filled with distilled water weekly, with the date noted. The Director of Nursing reiterated these expectations, emphasizing the responsibility of the night shift CNA and charge nurse to ensure compliance. However, the facility did not provide an Oxygen Policy by the end of the survey, indicating a systemic issue in managing respiratory care equipment.
Failure to Address Pharmacist's Medication Regimen Review
Penalty
Summary
The facility failed to respond to the pharmacist's monthly medication regimen review (MRR) for three residents, leading to deficiencies in medication management. Resident #38 had multiple recommendations from the pharmacist regarding cholesterol medication, missing labs, and gradual dose reductions, but there were no MRR reports or responses documented in the resident's medical record. The Director of Nursing (DON) was responsible for overseeing the MRR process but admitted to not receiving the reports from the pharmacy, resulting in a lack of response to the pharmacist's recommendations. Resident #8's care plan indicated the use of psychotropic medications, but the specific medications and reasons for use were not documented. The pharmacist recommended reviewing the Lorazepam order, but there was no response to this recommendation, and the resident's medical record lacked MRR reports or responses. The Assistant Director of Nursing (ADON) acknowledged that the MRRs were not being completed as required, and the recommendations were not being addressed by the physician. Resident #18 had an active order for Voltaren Gel without a specified dosage, and the pharmacist requested clarification to ensure proper administration. However, there was no response to this request, and the order remained unclear. Additionally, there was an order for the resident to be evaluated by psychiatric services, but this was not documented as completed. The DON and ADON both acknowledged the failure to ensure the MRRs were completed and addressed, leading to deficiencies in medication management for the residents involved.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage protocols were followed, resulting in two deficiencies. Firstly, a resident who had not been assessed for self-administration of medications and did not have a physician's order for self-administration was observed with a medicine cup containing multiple pills on their overbed table. The resident, who had been residing at the facility for about one and a half years, had diagnoses including pain, hypothyroidism, dementia, and hypertension. Despite being cognitively intact, the resident had impaired range of motion in both upper extremities and used a wheelchair. The resident's care plan included instructions to administer medications as ordered, yet the resident was left to take medications without staff supervision, as confirmed by an LPN and the DON. In a separate incident, the facility failed to ensure medication carts were locked when not in use. Observations revealed that a medication cart marked 'Diabetic' was left unlocked on two occasions, with residents in close proximity and no nurse present. The cart contained insulin, a medication used to decrease blood sugar. Interviews with a CMT, the ADON, and the DON confirmed that medication carts should be locked if not actively in use and that the responsibility for ensuring this lay with the staff using the cart and the charge nurse. These deficiencies highlight lapses in the facility's adherence to medication administration and storage protocols, potentially compromising resident safety. The facility's policy on resident self-administration of medication requires an interdisciplinary team assessment, which was not conducted for the resident in question. Additionally, the lack of a policy regarding keeping medication carts locked contributed to the oversight in securing the medication cart.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents, leading to discrepancies in their medical records. For one resident, the MDS inaccurately indicated the presence of a wound infection and unhealed pressure ulcers, despite the resident's skin being intact and no orders for wound treatments or antibiotics being present. Interviews with nursing staff confirmed that the resident did not have any wounds, and the MDS Coordinator acknowledged a coding error. The MDS Coordinator completed assessments remotely and did not communicate directly with the care staff, relying instead on electronic health records and remote meetings. Similarly, another resident's MDS inaccurately reported a wound infection, although no evidence of such a condition was found in the resident's care plan, medical records, or skin assessments. The corporate MDS Coordinator confirmed the coding error, noting that the resident's skin was intact during the assessment period. The Director of Nursing also confirmed that neither resident had wounds or infections, highlighting a failure in the facility's assessment and documentation processes.
Failure to Complete and Retain PASRR for Resident
Penalty
Summary
The facility failed to ensure the completion, submission, and retention of a Level I Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition (PASRR) for a resident. This screening is a federally mandated process for individuals with serious mental illness or intellectual disability who apply or reside in Medicaid-certified beds. The deficiency was identified for a resident who was admitted to the facility without a completed PASRR, as required by the facility's policy and state Medicaid rules. The resident's diagnoses included dementia, anxiety disorder, depression, and bipolar disorder, and the care plan indicated impaired cognitive function and the use of medications to treat mental illnesses. The Social Services Director (SSD) acknowledged during an interview that they had been responsible for PASRRs for the last few months but were not in charge when the resident was admitted. The SSD was unaware that PASRRs were not available online after a year and stated an intention to start printing and scanning them. The Director of Nursing confirmed that the SSD and a corporate staff member were responsible for completing PASRRs and that they should be completed before a resident's admission. The absence of a PASRR record in the resident's electronic health record highlighted the facility's failure to adhere to the required screening process.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide two residents, Resident #43 and Resident #44, with a baseline care plan within 48 hours of their admission, as required by the facility's policy. Resident #43, who was cognitively intact, was admitted on an unspecified date, but there was no documentation that the resident or their responsible party received a copy of the baseline care plan. The resident's admission Minimum Data Set (MDS) confirmed their cognitive status, yet during an interview, the resident did not recall receiving any baseline care plan. Similarly, Resident #44, who had short-term and long-term memory problems and severely impaired cognitive skills, was also not provided with a baseline care plan within the required timeframe. The Assistant Director of Nursing (ADON) admitted to not giving residents or their responsible parties the baseline care plans and was unclear about the responsibility for this task. The Director of Nursing (DON) confirmed that the ADON was responsible for the baseline care plans but had not been involved in providing them to residents or their representatives.
Incomplete Care Plan for Hospice Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who was on hospice care and had diagnoses of dementia and heart failure. The resident's admission Minimum Data Set (MDS) and Care Area Assessment (CAA) indicated the presence of a pressure ulcer, but the care plan lacked specific information about the location or stage of the ulcer. Additionally, the care plan did not include any focus items related to the resident's wounds or dementia, despite the presence of wound care orders for the pressure ulcer on the buttock and the wound to the left lower extremity. Interviews with facility staff revealed that the care plans were incomplete and behind schedule. The Registered Nurse (RN) acknowledged the lack of pertinent information in the care plan, and the Assistant Director of Nursing (ADON) admitted to not knowing who was responsible for updating the care plans. The Director of Nursing (DON) confirmed that the ADON and social services were responsible for adding information to the care plans and expressed an expectation for a completed comprehensive care plan for the resident. The absence of a comprehensive care plan could lead to staff not knowing how to properly care for the resident.
Failure to Follow Physician's Orders for Medication and Colostomy Care
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of medications for a resident with high blood pressure. The resident, who was cognitively intact but had a diagnosis of dementia, was prescribed Losartan and Carvedilol with specific instructions to hold the medication if blood pressure or pulse readings were below certain parameters. Despite these instructions, the medications were administered on multiple occasions when the resident's blood pressure readings were below the specified thresholds, as documented in the Medication Administration Record (MAR) for April and May 2024. Interviews with the LPN and the Director of Nursing confirmed that the nursing staff should not have administered the medications when the vital signs were out of the parameters set by the physician's orders. Additionally, the facility did not obtain physician's orders for the care of a colostomy for another resident who had recently undergone surgery on the digestive system. The resident, who was cognitively intact, had a colostomy and was at the facility to regain strength and learn how to care for the colostomy. The care plan included instructions for colostomy care, but the Physician's Order Sheet for May 2024 lacked any orders regarding the colostomy. Observations confirmed the presence of a colostomy bag, and interviews with the LPN and the DON indicated that there should have been specific orders for the care and management of the colostomy bag. These deficiencies highlight the facility's failure to follow physician's orders for medication administration and to obtain necessary orders for colostomy care, which are critical for ensuring the safety and well-being of the residents. The lack of adherence to these protocols was confirmed through interviews with facility staff and a review of the residents' medical records.
Deficient Discharge Procedures for Resident
Penalty
Summary
The facility failed to ensure proper discharge procedures for a resident, identified as Resident #53, who was discharged to a group home. The resident's medical records lacked critical information, including a recapitulation of stay, a reconciliation of medications, and documentation of the continuing care provider. The discharge summary was signed 10 days after the resident left the facility, and there was no evidence of communication with the group home regarding the resident's care needs or follow-up appointments. Interviews with facility staff, including the Social Service Designee (SSD), Licensed Practical Nurse (LPN), and Director of Nursing (DON), revealed several oversights. The SSD admitted to missing the notification to the Ombudsman and acknowledged the absence of documentation regarding the resident's follow-up care and the handling of medications and belongings. The LPN and DON confirmed that the discharge summary should have included a comprehensive list of medications, details of the resident's care while in the facility, and information about the physician taking over the resident's care. The resident's care plan and medical chart further highlighted the deficiencies, showing no documentation of the resident's belongings, medications, or follow-up care arrangements. The facility's failure to provide a policy for discharges at the time of exit contributed to the lack of proper discharge planning and communication, resulting in a deficiency in ensuring the resident's safe transition to the group home.
Failure to Monitor and Address Resident's Edema and Weight Gain
Penalty
Summary
The facility failed to adequately monitor and intervene in the decline of a resident's condition who was suffering from chronic venous hypertension and congestive heart failure. The resident's care plan, dated July 2023, indicated a need for staff assistance with lower body dressing due to lymphedema and a risk of worsening CHF, with interventions to monitor and report signs of edema. However, the care plan lacked specific information regarding the resident's venous hypertension or lymphedema. Despite physician notes documenting severe lymphadenopathy and the resident's reports of inconsistent application of a lymphedema compression device, the facility did not ensure consistent use of the device as ordered. Throughout the months from February to May 2024, the resident experienced significant weight gain, indicative of fluid retention, yet there was no documentation of actions taken in response to this change. The Treatment Administration Record (TAR) showed multiple instances where the lymphedema compression pump was not documented as applied during night shifts. Observations in May 2024 revealed the resident's legs were consistently edematous, red, and uncovered, with no compression devices in use. Interviews with the resident and staff confirmed the irregular use of the compression device and a lack of awareness or response to the resident's weight gain. The Director of Nursing acknowledged that there should have been parameters for reporting weight gain to the physician and orders to reduce edema, such as compression stockings and leg elevation. The DON expected staff to apply the lymphedema compression device as ordered and document its use, but this was not consistently done. The failure to monitor and address the resident's weight gain and edema, as well as the inconsistent application of the compression device, contributed to the deficiency in care provided to the resident.
Failure to Provide Addiction Recovery and Psychological Services
Penalty
Summary
The facility failed to provide necessary addiction recovery and psychological services for a resident who required participation in a recovery program to be eligible for a liver transplant. The resident, who had been admitted to the facility approximately two years prior, had a history of alcoholic cirrhosis of the liver, anxiety disorder, depression, and alcohol abuse in remission. Despite the resident's expressed desire to attend Alcoholics Anonymous (AA) meetings and the need for psychological services, the facility did not have a policy regarding support groups and failed to facilitate appropriate recovery support. The resident attempted to attend AA meetings but found the available option too religious and not suitable for their needs. The Social Services Designee (SSD) initially attempted to arrange transportation to a local church for AA meetings, but the resident expressed dissatisfaction with the religious nature of the meetings. The SSD did not follow up to find alternative AA meetings that aligned with the resident's preferences. Additionally, there was a lack of communication and coordination between the SSD and the resident, resulting in the resident not receiving the necessary support to meet the liver transplant program requirements. Furthermore, the facility did not ensure that the resident received psychological services for anxiety and depression, despite having physician orders for such services. The resident was only seen for psychotropic medication management and not for counseling. The Director of Nursing (DON) was unaware that the psychological services provider was not documenting in the facility's electronic health records, leading to a lack of proper documentation and follow-up on the resident's psychological needs. The facility's failure to provide adequate addiction recovery and psychological services resulted in the resident's inability to comply with the liver transplant program requirements.
Failure to Monitor Antipsychotic Drugs and PRN Orders
Penalty
Summary
The facility failed to appropriately monitor antipsychotic drugs and ensure PRN psychotropic drug orders did not extend beyond 14 days without physician rationale for a resident. The resident, who was severely cognitively impaired, was admitted with diagnoses of dementia with behavioral disturbance, depression, and anxiety. Despite receiving an antipsychotic medication daily, there was no documentation of behaviors or adverse effects, and the care plan lacked specific details about the psychotropic medications used and their purposes. The facility's policy required ongoing reassessments of changes in behavior, mood, and function, but this was not adhered to. The resident's behavior monitoring documentation was incomplete, with missing entries and unspecified behaviors to monitor. Additionally, the PRN order for Lorazepam was not discontinued after 14 days as required. Interviews with staff revealed a lack of awareness and completion of necessary monitoring tasks, indicating a systemic issue in medication management and documentation.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of insulin for a resident diagnosed with diabetes. The resident's care plan included instructions to administer diabetes medication as ordered, and the resident's Minimum Data Set confirmed the diagnosis and receipt of insulin shots. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that Novolog, a rapid-acting insulin, was administered multiple times when the resident's blood glucose levels were below the specified threshold of 150, contrary to the physician's order to hold the medication in such cases. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the nursing staff did not follow the physician's orders. The LPN acknowledged that medications outside of administration parameters should not have been administered, and the DON reiterated that the nursing staff needed to adhere to physician's orders, particularly when blood glucose levels were out of the specified parameters. The facility lacked a policy regarding this specific citation, contributing to the oversight.
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What surveyors actually found near you
We read the 119 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Oak Grove | 9.2 mi | ★★★★★ | 0 | 0 |
| Riverbend Heights Health & Rehabilitation | 12.3 mi | ★★★★★ | 1 | 0 |
| Meyer Care Center | 13.3 mi | ★★★★★ | 1 | 0 |
| Blue Springs Wellness & Rehabilitation | 15.9 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort St Marys Llc | 16.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.