Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Coral Rehabilitation And Nursing Of Austin during CMS and state inspections, most recent first.
The facility failed to ensure that grievances raised in Resident Council meetings were properly forwarded, reviewed, and answered in writing. Resident Council minutes showed repeated concerns about staff introducing themselves and call light response times, but the Activities Director did not consistently provide these grievances to the designated Grievance Official. The QA Director reported not receiving Resident Council grievances for an unknown period, and the Resident Council President stated that grievances were repeatedly brought up without evidence of resolution. Requested grievance records for the period reviewed were not provided, despite facility policies requiring review, written responses, and documentation of actions taken.
The facility failed to honor residents’ rights to manage their personal funds by not providing timely access to trust fund money, especially on weekends, and by not issuing accurate balance statements. A cognitively intact resident reported never receiving a statement and being unable to obtain the full amount needed to pay a phone bill, while two other residents reported not receiving their full monthly $75 allotments when requested, limiting their ability to purchase food and other items. Staff acknowledged that no one was available on weekends to disburse funds, that trust fund records were inaccurate and could not be reliably printed, and that there was no accessible trust fund policy despite a form stating that withdrawals must be documented and quarterly statements provided.
The facility failed to provide required quarterly written statements and maintain accurate records for resident trust fund accounts. A resident with intact cognition and mental health diagnoses reported never receiving a balance statement, not knowing her account balance, and only receiving partial funds when requesting money for bills, with no access to funds on weekends. Two other residents with cognitive communication deficits and cognitive impairment stated they were supposed to receive $75 monthly but were not given the full amount when requested, limiting their ability to purchase food. The ADM and a director confirmed the facility had not been keeping records of personal funds, including quarterly statements and withdrawals, and could not produce accurate trust fund statements or documentation of disbursements, despite a policy requiring documentation of all transactions and quarterly statements.
The facility failed to properly recognize, document, and route grievances related to unresolved concerns raised in resident council meetings and complaints about access to personal trust fund money. A cognitively intact resident council officer reported that grievances were repeatedly discussed in council meetings without resolution, and the Activities Director admitted she did not forward these council grievances to the designated Grievance Official. Another resident with severe cognitive impairment reported not receiving the full monthly amount of personal funds she was supposed to get, stating the facility said it would "run out" of money, and she had complained at the receptionist desk. Several staff, including the DON and other department heads, acknowledged that complaints about missing or delayed trust fund money could be grievances, yet no grievance forms were completed, and no grievance records were produced for the period reviewed, contrary to facility grievance and resident council policies.
The facility did not provide RN coverage for at least 8 consecutive hours on multiple days, despite a census of dozens of residents and a written policy requiring an RN on duty daily. Timecard records showed no RN worked on several specific dates, and interviews with HR, the DON, the ADM, and a director confirmed that staffing processes and meetings did not prevent these gaps. Staff acknowledged that an RN is required 8 hours per day for regulatory compliance, leadership, and to perform functions that LVNs cannot, and reported ongoing difficulty hiring additional RNs, including a weekend RN supervisor.
A facility licensed for 157 beds failed to employ a qualified full-time social worker over several months, despite regulatory requirements for facilities with more than 120 beds. Review of the facility summary and staff roster confirmed there was no social worker on staff, and there was no specific policy for a social worker, only a general acknowledgment that one was required. The QA Director reported that the prior social worker left and that she had been performing social services duties since then, believing this met the requirement as she had a similar degree, even though she did not hold the social worker title. The ADM and Director of Special Projects acknowledged the need for a social worker to address residents' psychosocial and related service needs, such as podiatry, dental, and vision, while asserting that resident care had not been negatively affected because the QA Director was covering these functions.
Surveyors found that care plans were not revised after significant incidents for two residents. One resident with multiple chronic conditions and moderately impaired cognition experienced a witnessed fall during a supervised smoke break, but this event was not added to the existing fall care plan. Another resident with communication and cognitive deficits, who had documented physical and verbal behaviors, was involved in a verbal/physical altercation requiring staff intervention, yet the care plan was not updated to reflect this aggression. The DON confirmed that these care plans were not revised after the incidents, despite facility policy requiring care plans to be reviewed and revised when new problems or goals are identified.
A resident with severe cognitive impairment and a history of strokes eloped from the facility after staff failed to monitor an exit door during an EMS response. The door's alarm system was not functioning, and staff were unaware of the malfunction. The resident was missing for several days before being found by law enforcement, during which time she was exposed to cold weather and missed her medications. The facility did not follow its elopement prevention policies, and the responsible party was not notified immediately.
A resident with severe cognitive impairment eloped from the facility and was not located for several days. Although staff notified law enforcement, the administrator, and family, the resident's court-appointed guardian was not immediately informed as required by policy. Interviews and records showed confusion among staff about notification responsibilities, resulting in a significant delay before the guardian was contacted.
A resident with chronic obstructive pulmonary disease and other conditions was using a CPAP machine as documented in care plans, progress notes, and hospital discharge summaries, but there was no corresponding physician order in the medical record. Nursing staff confirmed the resident's use of the CPAP machine, and the device was observed at the bedside, but the required physician order was not present as per facility policy.
A resident with multiple mobility and cognitive diagnoses experienced an unwitnessed fall resulting in injury, but the nursing staff did not notify the physician or family as required by facility policy. The resident was later found unresponsive and died after hospital transfer. Documentation of notification and neurological checks was incomplete, and interviews confirmed that required notifications were not made.
A resident with mobility and cognitive needs suffered an unwitnessed fall with a head injury, after which nursing staff failed to complete required neuro checks, notify the physician and family, and follow post-fall protocols. Incomplete documentation and lack of communication led to the resident being found unresponsive the next morning and passing away, with staff interviews revealing gaps in training and protocol adherence.
A resident with mobility and cognitive challenges experienced an unwitnessed fall resulting in head injury, but nursing staff failed to complete required neuro checks, post-fall assessments, and timely notifications to family and physician. The nurse involved lacked knowledge of fall protocols and EMR documentation, and the incident was not properly communicated or documented, leading to incomplete monitoring and a fatal outcome.
A facility failed to develop and implement complete person-centered care plans for two residents. One resident with gait instability and other medical issues had a fall with head injury, but the ordered fall protocol was not followed: neuro checks were incomplete, required assessments and notifications were not documented, and the resident was later found unresponsive. Another resident with bipolar disorder had that diagnosis documented in the chart and treated with medication, but it was not included in the care plan.
Failed pest control program allowed roaches, flies, spiders, and water bugs to remain in resident rooms, bathrooms, halls, dining areas, and the recreation room. Surveyors observed live roaches in a bathroom and hallway and bugs, webs, and dead insects near a handwashing station, while residents reported seeing pests almost daily and in group areas. Staff interviews showed confusion over who was responsible for contacting pest control, and the last documented service was months earlier.
Inaccurate MDS Assessments for Residents With Active Pressure Wounds: The facility failed to keep the MDS accurate for three residents with active pressure wounds. One resident had documented pressure ulcers to the buttock and sacrum, another had an open left buttock wound with ongoing wound care, and a third had documented pressure injuries and wound treatment orders, yet the quarterly/admission/reentry MDSs and resident matrix did not reflect current active pressure ulcers. The MDS Coordinator, DON, and ADM stated pressure ulcers are significant changes and that the assessments should be accurate, complete, and timely.
Failure to provide needed grooming and nail care for three residents was identified during survey. A female resident had long facial hair on her chin, while two residents had long, untrimmed fingernails that they said bothered them and were not being addressed. CNA and nursing interviews showed grooming and nail care were expected parts of ADL care, but staff were unaware of the missed care and the charting did not specify shaving or nail trimming for the affected residents.
Improper medication storage and labeling were observed in multiple medication storage areas and a med cart. In one storage room, a bottle labeled as Mucus relief contained different tablets, and an expired bottle of Stomahesive powder was present. In another storage room, an OTC calcium bottle was past its best-by date, the med refrigerator contained expired influenza vaccine plus strawberry juice and yogurt, and a mobile phone was stored in a nurses’ med cart with medications. Staff and the DON acknowledged that mixed medications, expired products, food in the med refrigerator, and personal items in the med cart were not appropriate.
Food items were found undated and unlabeled in kitchen storage areas, including an open bag of frozen dinner rolls in a freezer, an open bag of spaghetti noodles in a pantry, five loaves of bread, boxes of potatoes and bananas, and onions on a storage rack. Staff, the DM, DON, and ADM all stated that food in pantries, refrigerators, and freezers must be labeled and dated, and facility policy required stored food to be covered, labeled, and dated.
A resident’s room floor was observed to be sticky on repeated checks, including while the resident was in bed in the room. An LVN, HKS, and HK all acknowledged the sticky floor, and the HKS stated she missed the room during rounds. The resident had diagnoses including muscle weakness, lack of coordination, cognitive communication deficit, schizoaffective disorder, anxiety disorder, vascular dementia, and depressive disorders, and her BIMS score was 14.
Failure to complete PASRR re-screening for a resident with bipolar disorder. A resident admitted and readmitted to the facility had diagnoses including bipolar disorder and anxiety disorder, with MDS documentation showing intact cognition and depressive symptoms. Record review showed psychiatric and physician documentation of bipolar disorder, but the MDS nurse said she did not recognize the diagnosis, the DON believed a new PASRR level I was not needed because the resident had previously screened negative, and the facility policy did not address re-screening based on qualifying diagnoses.
Missing Baseline Care Plan for JP Drain and Incision Site Care: A resident admitted with multiple serious diagnoses had a JP drain in the LLQ, but the baseline care plan did not include drain management or incision site skin care. Records showed no physician order for JP drain or wound care, no documentation of care in the TAR/MAR/progress notes, and staff interviews confirmed they were unfamiliar with JP drain management, had not received training, and did not obtain the needed orders.
Failure to Provide JP Drain Care and Documentation A resident with a JP drain for pancreatitis-related care did not have a care plan or physician orders for drain and incision management, and the chart lacked documentation of drain or skin care. Staff reported they were unfamiliar with JP drain care, had not received facility training, and learned how to manage the drain from the resident’s family member. The resident stated the drain bulb had been leaking for several days and was being kept in a plastic bag, while the ADON, RN, and LVN acknowledged they provided care at times but did not document it or obtain the needed orders.
Infection Control Lapses During Peri Care and Wound Care: An LPN and a CNA provided peri care and wound care to a resident with hemiplegia, aphasia, a pressure ulcer, and other chronic conditions, but the CNA handled a wipe packet with feces-soiled gloves and contaminated the packet. The LPN then used the same overbed table for wound care items without a barrier, and neither staff member sanitized the table before leaving the room. Interviews confirmed both staff recognized the infection control breaches after the observation.
A resident with severe cognitive impairment and multiple comorbidities was found with a significant bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as unexplained and facility policy requiring prompt investigation, no investigation was initiated or completed to determine the cause of the injury.
A cognitively impaired resident with multiple risk factors for falls and requiring two-person assistance was not properly monitored or assisted during transfers, resulting in an unwitnessed injury and acute femoral fracture. Staff failed to follow fall protocols, did not complete required assessments, and inconsistently used the care plan or EMR to determine transfer needs, leading to a deficiency in accident prevention and supervision.
A resident with severe cognitive impairment and multiple comorbidities was found with a bruise and later diagnosed with an acute femur fracture of unknown origin. Despite staff recognizing the injury as suspicious and knowing the requirement to report such incidents, the event was not reported to the SSA within the mandated timeframe. Interviews confirmed that staff were aware of the policy but did not follow it, and there was no recent staff training on reporting injuries of unknown origin.
A resident with a tracheostomy did not have physician orders for trach care or suctioning, and nursing staff did not perform regular care, instead allowing the resident to manage his own trach without supervision or competency validation. The resident reused disposable cannulas and was later hospitalized with pneumonia. Another resident received trach care that did not follow infection control protocols, and multiple nurses reported inadequate training and lack of competency checks. These failures were identified as Immediate Jeopardy due to the risk of infection and respiratory complications.
A resident with chronic pain and complex medical needs was left without Hydrocodone due to the facility's failure to reorder the medication in time, resulting in severe, unrelieved pain and repeated requests for hospital transfer. Documentation discrepancies between the MAR and narcotic count sheet, as well as lack of follow-up pain assessments after PRN administration, were also identified. Nursing staff and providers were not notified promptly about the medication shortage, and facility policies for pain management and documentation were not followed.
A resident with a tracheostomy did not receive care according to professional standards, as observed when a nurse failed to perform hand hygiene, used non-sterile equipment, and did not follow required procedures for suctioning and oxygenation. Multiple nurses reported inadequate training and lack of competency validation for trach care, and the facility could not provide documentation of staff competencies. These failures led to an Immediate Jeopardy situation due to the inability of staff to safely care for residents with tracheostomies.
The facility did not provide two residents and their representatives with written notification of facility-initiated discharges, including reasons for the move, appeal rights, or Ombudsman contact information. Instead, families were informed by phone on the day of discharge or after the fact, with no written notice or options for alternative placements, and the required notifications to the Ombudsman were not made.
Two residents with pressure ulcers did not receive physician-ordered wound care on multiple days, and the facility failed to maintain complete and accurate medical records documenting these treatments. Staff interviews revealed confusion about responsibility for wound care in the absence of the wound nurse, leading to missed treatments and incomplete documentation.
A nurse failed to perform proper hand hygiene and did not use sterile technique while providing tracheostomy care and suctioning for a resident with complex medical needs, including respiratory failure and a tracheostomy. The nurse did not sanitize hands before and after glove changes, used non-sterile equipment, and did not follow facility policies for infection prevention, as confirmed by staff interviews and policy review.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not ensure that a resident with a colostomy had physician orders for its management, nor did it have orders specifying the dialysis schedule for two residents receiving regular hemodialysis. Staff interviews confirmed that these orders were expected but not present, which could result in missed care.
Several residents with open wounds and indwelling catheters did not have required PPE signage or supplies at their doors, and staff—including an ADON—were observed providing high-contact care without wearing gowns or following proper hand hygiene. Staff interviews revealed a lack of understanding about Enhanced Barrier Precautions, and the facility could not provide current hand hygiene or EBP policies when requested.
A resident with neurogenic bladder and an order for an indwelling foley catheter experienced a delay of over eight hours in catheter reinsertion after it was found to have come out. Despite the resident's repeated requests and staff awareness, the RN postponed the procedure, causing the resident discomfort and distress. The facility was unable to provide a catheter care policy when requested.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including staying in bed, inability to self-feed, and leg pain, over several days. Staff observed these changes but did not promptly notify the NP or responsible party, nor document the decline, resulting in delayed medical intervention. The resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture, and the facility was cited for failing to follow notification protocols.
A resident with a history of stroke, dementia, and chronic pain experienced a significant decline, including lethargy, inability to feed himself, and leg pain, which staff observed but did not promptly report or document. The lack of timely recognition and escalation led to delayed medical intervention, and the resident was later hospitalized with aspiration pneumonia, UTI, and a femur fracture. The facility did not follow its policy for notifying the physician and responsible party of significant changes in condition.
The facility did not maintain required indoor temperatures, resulting in several residents experiencing excessive heat in their rooms for extended periods. Despite multiple complaints and requests for fans or air conditioning, not all residents received relief, and temperature monitoring and documentation were inconsistent. Residents with conditions such as COPD, diabetes, and heart failure were affected, and staff interviews confirmed delays in addressing the air conditioning failures.
A resident with bipolar disorder and a history of aggression did not receive timely psychiatric evaluation or behavioral health interventions despite repeated physician orders and escalating behaviors, resulting in an altercation where another resident was injured. Staff and documentation confirmed ongoing behavioral issues and delays in psychiatric care, with inadequate monitoring and follow-up for both the resident exhibiting aggression and the resident who was harmed.
Two residents were involved in an incident where one pushed another's walker, resulting in a fall and a significant skin tear. Although the event was documented and reported internally to the DON and NP, it was not reported to the State Survey Agency as required by facility policy, due to the administrator's belief that there was no malicious intent. Both residents had complex medical and behavioral histories, and the failure to report the incident constituted a deficiency in abuse reporting protocols.
A resident with multiple medical and psychiatric diagnoses missed several doses of prescribed medications while out on pass, and staff failed to notify the physician or NP as required. Interviews and record review showed inconsistent practices and lack of documentation regarding provider notification, despite facility policy mandating prompt communication of missed medications.
A resident with multiple chronic conditions missed several doses of prescribed medications while out on pass, and staff failed to consistently notify the NP or physician or document these missed doses as required by facility policy. This resulted in a breakdown of pharmaceutical services and a deficiency in medication administration procedures.
Three residents did not receive timely dental care, including exams, denture placement, and cleanings, despite physician orders and care plan indications. Staff interviews revealed confusion about referral responsibilities, and the social worker had only recently arranged a new dental contract, with no dental visits yet scheduled. Facility policy required social services to assist with dental appointments, but documentation and follow-through were lacking.
A resident with multiple medical and psychiatric diagnoses experienced several falls that were documented in incident reports, but these events were not reflected in the resident's care plan. Staff interviews confirmed that falls should have been included in the care plan and that it is the responsibility of various team members to ensure updates. The facility's policy requires care plans to be comprehensive and revised as conditions change, but this was not followed, resulting in a deficiency.
Two residents experienced unsafe conditions due to inadequate wheelchair maintenance. One resident's wheelchair, which was from the 1960s, had a loose lock, posing a risk during transfers. Another resident's wheelchair brakes were not functioning, leading to a potential fall risk. Despite work orders and staff awareness, repairs were not completed timely, violating facility policies on maintenance and resident safety.
The facility failed to maintain resident dignity and privacy in two incidents. A CNA was observed using his phone during peri care for a resident with dementia, leaving her exposed. Another resident with a catheter was seen without a privacy bag, contrary to facility policy. Both incidents highlight lapses in respecting resident rights.
A resident receiving enteral nutrition through a gastrostomy tube was left lying flat, contrary to her care plan and facility policy, which required her head of bed to be elevated at least 30 degrees to prevent aspiration. The oversight was discovered by the resident's family member, who found her struggling to breathe with foam around her mouth. The family member intervened by elevating the bed, which alleviated the resident's breathing difficulties. Interviews with staff revealed a lack of communication and awareness regarding the incident.
The facility failed to develop baseline care plans within 48 hours for several newly admitted residents, who had various medical conditions. This deficiency was due to a backlog in care plans caused by recent management changes and staffing shortages, leading to potential miscommunication and inadequate care.
Failure to Address and Respond to Resident Council Grievances
Penalty
Summary
The deficiency involves the facility’s failure to ensure prompt efforts to resolve grievances raised through the Resident Council and to provide written responses to those grievances. Resident Council minutes for February 2026 and March 2026 documented repeat concerns from residents about staff introducing themselves and call light response times. The facility’s Resident Council policy required that concerns, grievances, and recommendations discussed in meetings be documented, that all written concerns be reviewed, that a written response be provided, and that documentation of actions taken be maintained. The facility’s Grievances Policy further specified that the Administrator designates a Grievance Official responsible for receiving and tracking grievances, conducting investigations, maintaining documentation, and ensuring written responses. Interviews with facility staff and the Resident Council President showed that grievances from Resident Council meetings were not being forwarded to or addressed by the designated Grievance Official. The Quality Assurance Director, who oversaw grievances, stated that the Activities Director had not been providing her with grievances from Resident Council for an unknown period of time, despite Resident Council meetings being a source of grievances and resident concerns. The Activities Director acknowledged receiving grievances from Resident Council and admitted she had not given the grievances from at least one Resident Council meeting to the Quality Assurance Director. The Resident Council President reported that grievances appeared not to be answered, as the same concerns were repeated at each meeting and the council had not heard of any grievances being resolved recently. When records of grievances since January 2026 were requested from the Quality Assurance Director, they were not provided.
Failure to Provide Timely Access and Accurate Accounting of Resident Trust Funds
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to manage their personal financial affairs and to provide timely access to their funds. Three residents with facility-managed trust funds reported not receiving full access to their money upon request and not receiving balance statements. One cognitively intact female resident with major depressive disorder and generalized anxiety disorder stated she had a trust fund but had never been given a statement and did not know her balance. She reported having to ask for money to pay her phone bill and only receiving whatever amount staff said was available, and that she could not request money on weekends. A male resident with moderate cognitive impairment and major depressive disorder reported he was supposed to receive $75 per month but did not receive the full amount at once despite asking, which affected his ability to buy outside food. Another female resident with severe cognitive impairment and a cognitive communication deficit reported she was also supposed to receive $75 per month, but the facility would not give her the full amount when requested because the facility would “run out,” and she used extra money to pay for food. Staff interviews and record review further showed systemic issues with management of resident trust funds. The receptionist stated that residents with trust funds received money through the facility but confirmed that no one was available on weekends to provide residents with their funds. The Administrator and Director of Special Projects acknowledged that residents were not being given their money in a timely manner and emphasized the importance of keeping records of residents’ personal funds, including quarterly statements and withdrawals. The Director of Special Projects reported they could not print trust fund statements because the records would be incorrect and that the facility was not keeping accurate records of trust fund transactions, leaving them without evidence of money disbursements. Although a “Resident Trust Account Authorization Form” referenced quarterly written statements and documentation of withdrawals, the facility was unable to produce a trust fund policy when requested, stating they could not locate one.
Failure to Provide Quarterly Trust Fund Statements and Maintain Accurate Personal Funds Records
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and document residents’ personal trust funds, including not providing required quarterly written statements for three residents with accounts held by the facility. One cognitively intact resident with major depressive disorder and generalized anxiety disorder reported having a trust fund but stated she never received a balance statement and did not know how much money she had, suggesting this had been occurring since the prior year. She reported having to ask the facility for money to pay her phone bill and only receiving whatever amount staff said was available, without being able to obtain the full amount requested, and stated she could not request money on weekends. Two other residents with cognitive communication deficits and varying levels of cognitive impairment reported they were supposed to receive $75 per month but were not given the full amount when requested. One resident stated he did not receive the full $75 at once despite asking, which affected his ability to buy outside food. Another resident stated she was supposed to get $75 per month, but the facility would not give her the full amount because the facility would “run out,” and she used extra money to pay for food. In an interview, the Administrator and Director of Special Projects acknowledged the facility had not been keeping records of residents’ personal funds, including quarterly statements and withdrawals, and that they could not print accurate trust fund statements or provide evidence of money disbursements because trust fund transactions were not being accurately recorded, contrary to the facility’s written policy requiring documentation of all withdrawals and provision of quarterly written statements.
Failure to Process and Address Resident Grievances and Trust Fund Complaints
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without discrimination or reprisal and to ensure grievances were properly identified, documented, and routed to the Grievance Official for follow-up. Resident #1, a cognitively intact female with major depressive disorder and generalized anxiety disorder, served as vice president of the resident council and reported that grievances were repeatedly brought up at resident council meetings without being answered, and that the council had not heard of any grievances being resolved recently. The Activities Director acknowledged receiving grievances from resident council, including those from March 2025, but admitted she had not forwarded these grievances to the designated Grievance Official, despite facility policy requiring documentation, review, written response, and maintenance of actions taken for resident council concerns. The facility also failed to treat residents’ complaints about not receiving their personal funds from trust accounts as grievances and to process them through the grievance system. Resident #3, a female with severe cognitive impairment (BIMS score 6/15) and a diagnosis including cognitive communication deficit, stated she was supposed to receive $75 per month but was not given the full amount when requested because the facility “would run out,” and that she had complained at the receptionist desk. Multiple staff, including the Director of Special Projects, DON, Medical Records/Central Supply personnel, and the Quality Assurance Director, acknowledged that residents’ complaints about not receiving their money could or did constitute grievances, yet no grievance forms were completed for these concerns. The DON reported hearing about residents not receiving their money during her first weeks at the facility in January 2026 and believed the former administrator was addressing the issue, but she did not write any grievances related to residents’ trust fund money. The Medical Records/Central Supply staff member confirmed residents had been asking for their money but could not receive the full amount because the facility did not have the funds, and she recognized this as a grievance but assumed it was already being worked on. The Quality Assurance Director, designated as the Grievance Official, stated she oversaw grievances, ensured they were given to the appropriate person, and followed up within three days, but she had not received grievances from resident council and was unaware that residents had concerns about not receiving their money. When surveyors requested records of grievances since January 2026, none were provided, despite facility policies outlining requirements for documenting and responding to grievances and resident council concerns.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were provided for at least 8 consecutive hours per day, 7 days a week, as required by regulation and the facility’s own Nursing Services Policy. Review of the Raw Punch Report for the period 03/01/2024 to 04/01/2024 showed there was no RN working on 03/01/2026, 03/05/2026, 03/28/2026, and 03/29/2026, despite a resident census of 74 residents on 04/01/2026. The facility’s written policy, revised 01/2026, stated that an RN will be on duty at least 8 consecutive hours per day, 7 days per week. During interviews, the HR staff member reported participating in staffing meetings with the staffing coordinator, administrator (ADM), and director of nursing (DON) to ensure RN coverage but stated she was unaware that the facility lacked an RN on the identified dates. She stated it was important to have an RN staffed 8 hours a day every day to ensure quality assurance and noted the facility had been unable to hire additional RNs, including a weekend RN supervisor. The DON stated she was available on call 24/7 and acknowledged it was important to staff an RN 8 hours a day because it was a state requirement, and reported there had been nothing that affected business operations, resident care, or psychological changes in residents. The ADM and Director of Special Projects stated the expectation was to have an RN 8 hours a day, emphasized the importance of leadership and that RNs can perform tasks LVNs cannot, and confirmed they were in the process of finding more RNs.
Failure to Employ Required Full-Time Social Worker for 157-Bed Facility
Penalty
Summary
The facility, licensed for 157 beds, failed to employ a qualified full-time social worker from January 2026 to April 2026, despite the regulatory requirement for a full-time social worker in facilities with more than 120 beds. Review of the Facility Summary Report confirmed the licensed capacity of 157 beds, and review of the undated staff roster showed there was no social worker employed at the facility during this period. The facility also did not have a policy specific to a social worker, although leadership acknowledged it was a general requirement to have one. During interviews, the Quality Assurance Director stated that the previous social worker had left around November 2025 and that she had been performing social services for residents since that time. She believed that as long as someone with a similar degree was performing social services, the facility met the requirement for having a social worker, even if that person did not use the title of social worker. The ADM and Director of Special Projects acknowledged that a social worker was needed for the number of beds in the facility and that it was important to have a social worker to meet residents' needs, including arranging podiatry, dental, and vision services. They stated there was no negative effect on resident care because the Quality Assurance Director was performing social worker duties after the prior social worker left, and they reported they were attempting to contact the former social worker and were actively seeking to hire a replacement.
Failure to Update Care Plans After Falls and Behavioral Incidents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure comprehensive care plans were reviewed and revised by an interdisciplinary team after each assessment and after acute incidents. For one resident with Type 2 diabetes, Crohn’s disease, asthma, dementia, major depressive disorder, and hypertension, the quarterly MDS dated 2/26/26 showed moderately impaired cognition and a need for supervision when walking up to 50 feet. The resident’s care plan documented a prior fall on 11/25/25 but contained no additional falls. However, progress notes and the facility’s incident log showed the resident sustained a witnessed fall on 1/22/26 during a supervised smoke break when another resident pushed her while reaching for a cigarette butt, and this fall was not added to or reflected in the care plan. A second resident, admitted with aphasia, memory deficit, cognitive social or emotional deficit, and cognitive communication deficit, had a comprehensive MDS dated 2/27/26 indicating intact cognition and documented physical and verbal behaviors toward others. The resident’s care plan identified a potential to demonstrate physical behaviors related to anger and poor impulse control, but there were no updates following an incident on 2/13/26. Progress notes and the incident log documented that staff had to intervene and separate this resident from another resident due to verbal/physical aggression on that date, yet the care plan was not revised to reflect this event. During interview, the DON acknowledged that the care plans for both residents had not been updated after these incidents and stated that the MDS nurse was responsible for updating care plans after acute incidents, and that care plans are expected to be reviewed and revised when new problems or goals are identified per facility policy.
Failure to Prevent Resident Elopement Due to Unmonitored Exit and Non-Functioning Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of strokes, and impaired safety awareness eloped from the facility. The resident was able to exit through a door in Unit 3 vicinity hall 100, which was not properly monitored or secured during an EMS response for another resident's medical emergency. The door's 15-second delay alarm system was not functioning correctly, and staff were unaware of the malfunction. The resident was last seen in her room by staff and was later found missing during routine rounds. The facility's records indicated that the resident was considered low risk for elopement, and there was no prior evidence of exit-seeking behavior, but she had a history of confusion and required redirection when wandering into previous rooms. Staff interviews revealed that during the time of the emergency involving another resident, the exit door used by EMS was not monitored, and staff attention was diverted. Multiple staff members, including the DON, LVNs, and CNAs, stated they were not aware that the exit door alarm was not working. Additionally, it was observed that residents with high cognitive scores had access to the keypad code for the exit doors, and there was no list of which residents knew the codes. The facility's logbook for door checks was incomplete, and not all exit doors were being checked as required by policy. The resident was missing for several days, during which time she was exposed to cold weather and missed her medications, before being found by law enforcement on a bus and taken to the hospital. The facility failed to follow its own elopement prevention and response policies, which required all exit doors to have functioning alarms and to be checked each shift, as well as monitoring of doors during EMS entry and exit. The responsible party (guardian) was not notified immediately of the resident's elopement, and there was a delay in communication. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's elopement and exposure to potential harm.
Removal Plan
- Resident #8 was readmitted to a room across from the nurse's station for better monitoring and placed on one-to-one supervision to assure safety and monitor for elopement tendencies.
- Implement a check procedure with nursing to document Resident #8's presence.
- Activities and meal attendance for Resident #8 will be completed with an escort.
- All exit doors were checked by Maintenance to confirm alarms were operational and documented.
- Any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.
- A full resident headcount was completed by the DON to ensure no other residents were missing or unaccounted for.
- All on-duty staff were re-educated on elopement prevention policy, door-monitoring requirements during emergencies, and that exit codes will not be shared with residents or visitors.
- Random competency quizzes will be completed.
- Exit door audits will be completed.
- Review of elopement risk assessments for all residents, including Resident #8.
- Full staff retraining on elopement procedures, supervision, and emergency response for all active personnel, with PRN or leave staff retrained prior to return.
- Maintenance audit of all door alarms will be completed.
- Administrator/DON will audit 100% of EMS entry/exit logs, door monitoring logs, and elopement assessments.
- Mock elopement drills will be completed.
- All audits and drill results will be reviewed in Standards of Care meetings, with immediate corrective action for any deviations.
Failure to Immediately Notify Guardian After Resident Elopement
Penalty
Summary
The facility failed to immediately notify the resident's legal representative, a court-appointed guardian, after the resident eloped from the facility. The resident, an elderly female with severe cognitive impairment due to multiple strokes and other significant medical conditions, was discovered missing during evening rounds. Staff initiated a search, notified law enforcement, the administrator, the DON, and family members, but did not promptly contact the resident's guardian as required by facility policy and federal regulations. Record reviews and interviews revealed that the resident's guardianship had been established due to her cognitive deficits, and the guardian was listed as the responsible party. Despite this, there was confusion among staff regarding who was responsible for notifying the guardian, with some assuming that management would handle the notification. Documentation and interviews indicated that the guardian was not notified until several hours after the resident was found missing, with conflicting accounts of the exact timing of notification. The facility's policy required immediate notification of the legal representative within one hour of recognizing a significant change in the resident's condition, such as elopement. The delay in notifying the guardian was confirmed by both facility staff and the guardianship agency. The resident was eventually found several days later by a bus driver and transported to the hospital, where she was admitted for further assessment. The hospital case manager also noted that the guardian had not been notified in a timely manner about the elopement. The deficiency centers on the facility's failure to promptly inform the resident's legal representative of a significant event affecting the resident, as required by policy and regulation.
Missing Physician Order for CPAP Machine
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was using a continuous positive airway pressure (CPAP) machine. Record reviews showed that while the resident's care plan, progress notes, and hospital discharge summary all referenced the use of a CPAP machine at night, there was no corresponding physician order for this treatment in the monthly physician orders for the relevant period. The resident's face sheet and Minimum Data Set (MDS) assessments also documented the use of the CPAP machine, and direct observation confirmed the presence of the device at the bedside. Interviews with nursing staff confirmed the resident's use of the CPAP machine, but staff were unaware of why the physician order was missing from the records. The Director of Nursing (DON) acknowledged that the omission may have occurred during the resident's discharge and subsequent re-admission, resulting in the physician order not being reactivated. The facility's policy requires that all drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the CPAP machine. The deficiency was identified through observation, interview, and record review, which collectively demonstrated that the facility did not ensure the resident's medical record was complete and accurately documented regarding the use of the CPAP machine.
Failure to Notify Physician and Family After Resident Fall Resulting in Death
Penalty
Summary
The facility failed to immediately notify a resident's physician and family member following an unwitnessed fall that resulted in injury and ultimately the resident's death. The resident, a male with diagnoses including muscle weakness, unsteadiness on feet, cognitive communication deficit, and muscle wasting, was assessed as being at risk for falls and required assistance with mobility. After experiencing an unwitnessed fall, the resident was found with redness on the back of his head and neck, but there was no documented evidence that the physician or family were notified of the incident. Nursing staff involved in the incident did not recall or document notifying the physician or the resident's family member after the fall. The nurse who responded to the fall assessed the resident but did not inquire if the resident had hit his head, nor did she notify the physician or family. Subsequent staff were not informed of the fall, and the resident was later found unresponsive and subsequently passed away after being transported to the hospital. The family was only notified when the resident was being sent to the hospital, and observed injuries at that time. Interviews with facility leadership and staff confirmed that the facility's policy required immediate notification of the physician and family after such incidents, but this was not followed. Documentation related to neurological checks and notifications was incomplete or missing. The physician stated he was not notified of the fall and expected to be informed of such events due to the risk of head trauma. The failure to notify the appropriate parties was identified as an Immediate Jeopardy situation by surveyors.
Failure to Protect Resident from Neglect After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to protect a resident's right to be free from neglect following an unwitnessed fall with a head injury. The resident, who had a history of muscle weakness, unsteadiness, and required assistance for mobility, experienced an unwitnessed fall in the evening. The nurse on duty assessed the resident and noted redness on the back of the head/neck area but did not complete or document ongoing neurological checks as required by facility policy. Additionally, there was no documentation of family or physician notification regarding the fall, and the facility's fall protocol and the resident's person-centered care plan were not followed. The medical record review revealed that neurological monitoring was only initiated for a short period and was incomplete, with the remainder of required checks not performed or documented. The nurse did not complete an incident report, and the post-fall evaluation, including assessments for delayed complications and changes in the resident's condition, was not conducted. The resident was found unresponsive the following morning and subsequently passed away. Interviews with staff confirmed a lack of communication and understanding of the facility's fall protocol, as well as insufficient training and knowledge regarding required post-fall assessments and documentation procedures. Further interviews with facility leadership and staff indicated that the nurse responsible for the initial assessment lacked adequate training on the facility's electronic medical record system and was unaware of the full scope of required post-fall procedures. The failure to follow established protocols, conduct ongoing monitoring, and communicate with the physician and family constituted neglect, as defined by facility policy and federal regulations. The deficiency was identified as Immediate Jeopardy due to the systemic failures in assessment, documentation, and communication following the resident's fall.
Failure to Ensure Nursing Staff Competency in Post-Fall Assessment and Notification
Penalty
Summary
Nursing staff at the facility failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall. The resident, who had a history of muscle weakness, unsteadiness, and mobility issues, was found to have fallen and sustained redness to the back of his head and neck. Despite these findings, there was no documented evidence that neurological checks were properly conducted, nor that the resident’s family or physician were notified of the incident. The nurse involved did not complete the required post-fall assessments or incident report, and only provided an oral report to the DON. The nurse also lacked knowledge of the facility’s fall protocol, procedures, and the use of the EMR system, having received only minimal training before being assigned as charge nurse. Further review revealed that the last documented fall risk or post-fall evaluation for the resident was not completed for the most recent fall, and there was no follow-up for delayed complications related to the incident. The neurological monitoring initiated was incomplete, and subsequent checks were not performed as required. Other staff, including the RN on the following shift, were not informed of the fall and therefore did not continue necessary monitoring. Interviews with facility leadership confirmed that the fall protocol was not followed, care plan interventions were not implemented, and required documentation was missing. The facility’s policies required immediate and ongoing assessment, documentation, and notification following a fall, none of which were adequately carried out in this case. The resident was later found unresponsive and subsequently passed away after being transported to the hospital. Interviews with family members indicated they were not notified of the fall until after the resident was sent to the hospital. The physician also confirmed he was not informed of the fall. Facility leadership acknowledged that the expected protocols and procedures were not followed, and that the nurse involved did not possess the necessary competencies to perform required assessments or documentation. The failure to ensure staff competency and adherence to protocols placed residents at risk for significant harm.
Incomplete Care Planning and Failure to Follow Fall Protocol
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, including measurable objectives and timeframes tied to their assessed needs. One resident was admitted with diagnoses including muscle weakness, unsteadiness on feet, gait and mobility abnormalities, cognitive communication deficit, and muscle wasting and atrophy. His care plan identified him as being at risk for falls related to deconditioning and gait/balance problems and included an intervention to follow the facility fall protocol, but the intervention was not carried out after an unwitnessed fall with a head injury. After the fall, the resident was assisted back into his wheelchair and assessed, with redness noted on the back of his head/neck area. The record did not show that neurological checks were completed as required, and the family and physician were not notified at the time of the fall. The resident was later found unresponsive the next morning and CPR was initiated until EMS arrived. Review of the record also showed no fall risk/post-fall evaluation for the incident, no documented follow-up for delayed complications related to the fall, and no nurse or PT assessment of the resident’s ability to rise from a chair after the fall. Interviews with nursing staff, the ADON, and the DON confirmed that the fall protocol was not followed and that the required monitoring, documentation, and notifications were not completed. The facility also failed to include Resident #33’s bipolar disorder in her care plan. Her record showed diagnoses including CHF, muscle weakness, lack of coordination, cognitive communication deficit, diabetes mellitus, pacemaker, HTN, anxiety disorder, and bipolar disorder. Her MDS reflected bipolar and anxiety disorders, and progress notes and psychiatric records documented treatment for bipolar disorder, including medications ordered for that diagnosis. However, the care plan did not contain interventions for bipolar disorder. During interview, the resident stated she had flexible moods at times and received medications regularly for her mental wellbeing.
Failed Pest Control Program Allowed Roaches and Other Pests Throughout Facility
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests and rodents in residents’ rooms, bathrooms, halls, dining areas, and the recreation room. Survey observations found live roaches in a resident’s bathroom, a large roach crawling on a room nameplate in a hallway, and bugs including flies, small roaches, spiders, and spider webs in the recreation room. A handwashing station near the recreation room also had multiple dead bugs on the countertop. Resident interviews and a confidential group interview showed repeated complaints about pests throughout the facility. One resident stated he saw very small roaches in his room almost every day and had asked staff for roach spray, but staff would not provide it; he also said he had reported the issue to the DON and did not recall the last time pest control had been seen. Another resident reported big cockroaches in the facility and said staff had said they would spray, but he had not seen anyone do so. During the group interview, 8 of 8 residents reported seeing pests such as big roaches and flies in their rooms, restrooms, dining room, and recreation room, and surveyors observed flies landing on residents during the interview. Record review and staff interviews showed the last pest control log entry was dated 06/20/25. The MTA stated he was now in charge of pest control because there was no maintenance director, and said pest issues were supposed to be logged in the pest control binder, but the last treatment had been in June 2025. The DON stated she had not seen pest control come since she started and believed the MTA was responsible for contacting pest control. The ADM stated she was responsible for pest control, called pest control after hearing reports, and said the last time pest control had been in the building was June 2025. The facility’s pest control policy stated it maintained an ongoing pest control program to keep the building free of insects and rodents.
Inaccurate MDS Assessments for Residents With Active Pressure Wounds
Penalty
Summary
The facility failed to ensure the comprehensive assessment accurately reflected the status of three residents with active pressure wounds. For Resident #1, the quarterly MDS dated [DATE] indicated the resident was at risk for pressure ulcers but did not identify any unhealed pressure ulcers or injuries. The resident’s record showed diagnoses including pressure ulcer of the right buttock stage 3 and pressure ulcer of the sacral region stage 4, and a nursing note dated 08/28/25 documented a coccyx wound measuring 2 cm x 2 cm with 1 cm depth after staff observed bleeding during a shower. A NP wound note dated 09/10/25 listed current wounds on the left buttock, sacrum, and right buttock as pressure ulcers stage 3. For Resident #17, the admission MDS dated [DATE] also marked the resident as at risk for pressure ulcers but did not identify any unhealed pressure ulcers or injuries. The resident’s face sheet listed diagnoses including lymphedema, protein calorie malnutrition, morbid severe obesity, and edema. The record included a nursing note dated 08/26/25 stating the wound NP saw the resident and noted an open area to the left buttock measuring 1 cm in diameter. An eMAR note dated 09/11/25 documented ongoing wound care to a pressure ulcer on the left buttock, including cleansing with wound cleanser, application of triad paste and collagen mixture, and leaving the area open to air. For Resident #70, the quarterly MDS dated [DATE] and the reentry MDS dated [DATE] did not reflect active pressure injuries, even though the resident’s face sheet listed pressure ulcer of the left buttock stage 2 and the active diagnosis list included that condition. The care plan and progress notes showed ongoing wound-related concerns, including a nursing note dated 08/29/25 describing left heel deep tissue injuries, redness on the bottom, and a small ulcer on the right thigh, and a nursing note dated 09/02/25 documenting an open pressure ulcer to the right buttock measuring 2.5 cm x 3 cm with scant exudate. Additional documentation included wound care orders for the left heel and a skin assessment noting the left heel had closed up. The facility resident matrix dated 09/09/25 did not mark any of the three residents as having current or active pressure ulcers. In interviews, the MDS Coordinator, DON, and ADM stated that pressure ulcers are significant changes requiring the MDS to be updated and that the assessments should be accurate, complete, and timely; they also stated the matrix was inaccurate because it did not reflect the residents’ current pressure ulcer status.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for three residents reviewed for ADLs. Resident #9, a male with diagnoses including schizoaffective disorder, bipolar disorder, muscle weakness, cognitive communication deficit, cataracts, glaucoma, and legal blindness, was assessed as cognitively intact with supervised to moderate assistance needed for all ADLs and had a care plan calling for assistance and verbal encouragement with grooming and other daily living needs. Resident #18, a female with diagnoses including syncope and collapse, muscle weakness, cognitive communication deficit, speech and language deficits following cerebral infarction, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, depressive episodes, and memory deficit, was also assessed as cognitively intact with supervised to moderate assistance needed for all ADLs and had a care plan calling for assistance and verbal encouragement with grooming and other daily living needs. Resident #44, a male with diagnoses including Asperger's syndrome, anemia, cognitive communication deficit, type 2 diabetes mellitus, muscle weakness, and reduced mobility, was documented as cognitively intact and independent with all ADLs on the MDS, yet his care plan stated he was dependent and needed assistance and verbal encouragement with grooming and other daily living needs. During interview and observation, Resident #18 stated she had facial hair on her chin and that staff usually shaved it, but she had not always been shaved and it bothered her. CNA C stated residents are shaved during shower times or when care is provided, that Resident #18 gets shaved every other week, and that she sometimes did not have a razor available. On observation, Resident #18 had multiple long hairs on her chin approximately 2 inches long, and later the resident was observed shaved. Resident #9 stated he did not like his fingernails long, wanted them trimmed, and felt upset when they were not trimmed; his fingernails were observed to be approximately an inch past the nailbed and remained untrimmed on later observation. Resident #44 stated his fingernails were untrimmed, that staff had not trimmed them or asked him about trimming them, and that he felt staff were ignoring his care; his fingernails were observed to be approximately a half inch past the nailbed and remained untrimmed on later observation. Staff interviews reflected that shaving and nail care were expected parts of ADL care and were documented in PCC, with CNA and nursing staff both describing responsibility for maintaining grooming and nail care, and noting that residents should be shaved and have fingernails trimmed weekly or as needed. CNA C stated she had not asked about Resident #44's diabetic status and did not know where to verify it, and she stated she had not asked about Resident #44's fingernail trimming. LVN B and the DON both stated they were unaware that Resident #18 had chin hair that had not been shaved for a long period, were unaware of Resident #9's long untrimmed fingernails, and were unaware of Resident #44's long fingernails and broken hanging fingernail. Record review of the residents' ADL documentation showed daily ADL entries from mid-August through the survey dates, but there was no specification for fingernail trimming for Residents #9 and #44 or shaving for Resident #18. The facility's ADL Supporting policy stated residents unable to carry out ADLs independently will receive services necessary to maintain grooming and personal hygiene, including bathing, dressing, grooming, and oral care.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the Hall 200 medication storage room, the Hall 100 medication storage room, and the Hall 100 nurses’ medication cart. In the Hall 200 medication storage room, surveyors observed one bottle of Mucus relief containing a pink round tablet and three pink oval tablets, even though the bottle label identified a different medication, and one bottle of Convatec Stomahesive Protective Powder that was expired. In the Hall 100 medication storage room, surveyors observed one bottle of oyster shell calcium 500 mg with a best-by date of 04/25, and the medication refrigerator contained three packets of influenza vaccine labeled with an expiration date of June 30, 2025, along with a bottle of strawberry juice and a packet of strawberry yogurt. In the Hall 100 nurses’ medication cart, surveyors observed a mobile phone stored in the last drawer with medications. During interviews, an LVN stated that different medications should not be mixed in one bottle and that expired medications should be discarded in a timely manner. Another LVN stated food items should not be stored in the medication refrigerator, and an RN stated personal items such as mobile phones should not be kept in the med cart because they were a threat to cross contamination of medications. The DON stated the expired medications and the bottle containing a mixture of different medications should have been thrown away, that food items should not be stored with medications in the refrigerator, and that the mobile phone in the med cart could cause cross contamination.
Food Items Found Undated and Unlabeled in Kitchen Storage Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one reviewed kitchen. During a walk-through of the kitchen, surveyors observed an open bag of frozen dinner rolls in one freezer that was undated and not labeled. Surveyors also observed an open bag of spaghetti noodles in one pantry that was undated and not labeled. Additional observations in the kitchen showed five loaves of bread that were undated and not labeled in one pantry, a box of potatoes that was undated and not labeled on a storage rack, two boxes of bananas that were undated and not labeled on a storage rack, and ten onions that were undated and not labeled on a storage rack. On a later walk-through, surveyors again observed an open bag of spaghetti noodles that was undated and not labeled in one pantry, along with a box of potatoes that was undated and not labeled on the kitchen storage rack. During interviews, kitchen and nursing staff, the DM, DON, and ADM stated that all food products in the kitchen need to be labeled and dated, including items in pantries, refrigerators, and freezers. They stated that food not labeled or dated should not be served and should be discarded. Facility records showed dietary in-services on food storage and policies requiring all food stored in refrigerators or freezers to be covered, labeled, and dated, with supervisors responsible for ensuring pantry, refrigerator, and freezer items are not expired or past perish dates.
Sticky Resident Room Floor
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for Resident #18 when her room floor remained sticky during two observations on 09/09/25. At 12:14 PM, the resident was not in her room and the floor was observed to be sticky. At 3:30 PM, the resident was lying in bed in her room, and the floor was still sticky. The surveyor attempted to interview the resident, but she did not answer questions. During the 3:31 PM observation, an LVN entered the room and stated that the floor was sticky, and said housekeeping staff were responsible for mopping residents’ floors. The LVN stated housekeeping had mopped the floor a couple of minutes before the surveyor’s observation. At 3:38 PM, the HKS entered the room, observed that the floor was sticky, and stated housekeepers were responsible for cleaning residents’ rooms before breakfast, after lunch, and after dinner, and that floors were mopped 2-3 times daily. She stated housekeepers did not document mopping residents’ floors and acknowledged, “Yeah I missed this room during my rounds.” At 3:41 PM, an HK also entered the room, observed the floor was sticky, and stated floors were mopped 2-3 times daily. The resident’s record reflected diagnoses including muscle weakness, lack of coordination, cognitive communication deficit, schizoaffective disorder, anxiety disorder, vascular dementia, and depressive disorders, and her quarterly MDS showed a BIMS score of 14, indicating she was cognitively intact.
Failure to Complete PASRR Re-screening for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to refer a resident with a newly evident or possible serious mental disorder for PASRR level II resident review after a significant change in status assessment. Resident #33 was a female admitted and readmitted to the facility with diagnoses including congestive heart failure, muscle weakness, lack of coordination, cognitive communication deficit, diabetes mellitus, pacemaker, hypertension, anxiety disorder, and bipolar disorder. Her quarterly MDS showed a BIMS score of 13, indicating intact cognition, and documented bipolar and anxiety disorder, with feelings of being down, depressed, and hopeless nearly every day over the prior two weeks and feeling bad about herself most days. Her care plan did not include interventions for bipolar disorder or anxiety disorder. Record review showed a geriatric progress note and a psychiatric initial assessment documenting bipolar disorder without dementia, and physician orders included lamotrigine and levetiracetam related to bipolar disorder. The MDS nurse stated she was responsible for identifying PASRR-eligible residents but was not aware the resident had bipolar disorder and said she was overwhelmed with multiple tasks. The DON stated she believed a new PASRR level I assessment was not needed because the resident had previously screened negative for mental illness before admission, and the ADM stated the MDS nurse was responsible for identifying PASRR-eligible residents. The facility policy described PASRR screening for new admissions and readmissions, but did not include re-screening residents based on qualifying diagnoses.
Missing Baseline Care Plan for JP Drain and Incision Site Care
Penalty
Summary
The facility failed to ensure Resident #55 had a baseline care plan that included the minimum healthcare information needed to properly care for him within 48 hours of admission. Resident #55 was a [AGE]-year-old male admitted with encephalopathy, acute pancreatitis with infected necrosis, hepatic fibrosis, acute respiratory failure, muscle weakness, lack of coordination, and reduced mobility. His initial MDS showed a BIMS interview had not yet been conducted. Record review showed the care plan dated 06/08/28 did not include care for the Jackson Pratt drain or skin care at the incision site. The physician’s order record on 09/11/25 also did not contain an order for wound care of the incision site or management of the Jackson Pratt drain. The TAR, MAR, and progress notes contained no documentation of care provided for the JP drain or skin since admission. A progress note on 09/03/25 documented that the resident arrived by EMS with an accordion JP drain in the LLQ, described as brown with no smell, and a 09/04/25 note stated three of four pancreatic drains had been removed, with one remaining drain producing about 200 mL/day of brown fluid. During observation on 09/09/25, the resident was in his room with the JP drain inserted to the LLQ of his torso, and he stated the bulb had been leaking for the last 4 days and had not yet been replaced by the facility. He also stated staff told him an order for the bulb had been placed and was waiting for delivery, and that staff did not know how to manage his condition due to lack of experience with JP drains. Interviews with the ADON, RN, and LVN A showed they were providing some drain care but had not documented it, had not received training on JP drain management, and had not requested physician orders for the drain or incision site care. The MDS coordinator stated no JP drain care plan was made because no one reported it to her, and the DON stated the admission nurse was responsible for the baseline care plan, with the MDS coordinator responsible for ensuring it was completed in a timely manner.
Failure to Provide Ordered JP Drain and Incision Care
Penalty
Summary
The facility failed to ensure that Resident #55 received treatment and care in accordance with professional standards of practice and the comprehensive care plan for his Jackson Pratt drain and incision site. Resident #55 was admitted with diagnoses including encephalopathy, acute pancreatitis with infected necrosis, hepatic fibrosis, acute respiratory failure, muscle weakness, lack of coordination, and reduced mobility. Records showed that after admission there was no care plan for the Jackson Pratt drain, and there was no physician order for wound care of the incision site or management of the drain. Review of the TAR, MAR, and progress notes also showed no documentation of care provided for the drain or skin since admission. During observation, Resident #55 had a Jackson Pratt drain in the left lower quadrant of his torso, and the bulb was secured in a plastic bag because it was leaking. The resident stated the bulb had been leaking for the last 4 days and had not yet been replaced by the facility. He also stated staff were attentive but did not know how to manage his condition because of lack of experience with Jackson Pratt drains, and that he mostly drained the fluid from the bulb himself. The incision site was observed without signs of infection at that time. Interviews with facility staff showed that the ADON, RN, and LVN all provided drain care at times but did not document it, and none had received facility training on Jackson Pratt drain management. The ADON stated she did not look at the care plan or call the physician for drain and incision management orders. RN G stated she drained the JP drain when on duty and had learned how to manage it from the resident’s family member. LVN A stated she admitted the resident, did not request physician orders for drain management or incision care, and did not make a baseline care plan. The NP stated the drain and incision management were supposed to be done daily and expressed concern about admitting the resident with a JP drain, noting the leaking bulb should have been replaced as soon as it was found defective.
Infection Control Lapses During Peri Care and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #70 during peri care and wound care. Resident #70 was a [AGE]-year-old male with hemiplegia, aphasia, muscle weakness, muscle wasting and atrophy, a stage 2 pressure ulcer of the left buttock, cognitive communication deficit, urinary retention, hepatitis C, hypertension, chronic kidney disease, and a need for assistance with personal care. His MDS indicated the BIMS interview could not be conducted because he was rarely or never understood, and his care plan included wound management services for bilateral buttock incontinence associated dermatitis with wound care per treatment order. During observation, CNA J and LVN I were providing peri care and wound care to Resident #70. CNA J put on gloves after handwashing, opened the brief, and cleaned feces from the resident’s back using wet wipes taken directly from the packet. While doing so, he handled the entire wipe packet multiple times with gloves soiled with feces. LVN I held the resident on his side while CNA J cleaned him, and after the cleaning was completed, LVN I performed wound care to the buttocks pressure ulcer. LVN I used the same overbed table that had the contaminated wet wipe packet on it to place wound care items, without using a disposable cloth or paper towel as a barrier. After the peri care and wound care were completed, CNA J and LVN I left the room without sanitizing the overbed table. In interviews, CNA J stated he had contaminated the whole packet and should have thrown it away, and LVN I stated she had not realized the packet was contaminated and should have redirected CNA J. The DON stated CNA J should not have handled the wet wipe packet with soiled gloves, should have discarded the contaminated packet, and the overbed table should have been sanitized before leaving the room.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated for one resident who experienced an injury of unknown origin. Staff observed the resident with discoloration on the buttocks, which was later confirmed to be associated with an acute, mildly displaced comminuted right proximal femoral fracture. Despite the presence of a significant injury and the facility's policy requiring prompt and thorough investigation of injuries of unknown origin, there was no documentation or evidence that an investigation was initiated or completed to determine the cause of the injury. Multiple staff members, including CNAs, RNs, the ADON, and the DON, acknowledged that the injury was of unknown origin and recognized the importance of investigating such incidents. The DON stated that she was informed of the injury and instructed staff to notify the physician and obtain an x-ray, but did not initiate or conduct an investigation. The ADM, who was responsible for investigating injuries of unknown origin, reported not being notified of the incident until informed by surveyors and confirmed that no investigation had been conducted. The facility's own policy, revised in December 2024, required that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by management. Despite this, interviews and record reviews confirmed that the required investigation did not occur, and there was no evidence to show that the facility attempted to determine how the resident sustained the injury.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for a cognitively impaired resident with a high risk for falls. The resident, who had severe cognitive impairment, bilateral hip osteoarthritis, osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and right eye blindness, required substantial to maximal assistance with transfers and was care planned for two-person assistance. There was no documentation indicating the use of a mechanical lift for transfers, despite this being required. On the day prior to the resident's hospital transfer, staff observed the resident had pain and dark discoloration on the buttocks during repositioning for perineal care. The resident reported having fallen, but could not provide details. Staff did not complete a skin assessment as required, and there was no documentation of an accident or incident prior to the discovery of the injury. The resident was later found to have an acute, displaced femoral fracture and was sent to the hospital for surgery. Multiple staff interviews revealed inconsistent knowledge and practices regarding the resident's transfer status, with some staff relying on verbal reports or outdated lists rather than the care plan or electronic medical record (EMR). Further interviews indicated that staff, including CNAs and nurses, were not consistently following the facility's fall protocol when a cognitively impaired resident reported a fall or presented with a new skin issue. The facility's policies required notification of the physician and responsible party, completion of assessments, and documentation of incidents, but these steps were not followed. The resident's roommate reported that staff often used only one-person assistance for transfers, and there was uncertainty among staff about the proper use of mechanical lifts. There was also a lack of in-service training related to fall protocol, transfers, and accident/incident management during the relevant period.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. Specifically, staff observed a resident with discoloration to the buttocks area, which was later confirmed as an acute femur fracture. Despite multiple staff members, including the ADON, DON, and CNA, recognizing the injury as one of unknown origin and acknowledging the requirement to report such incidents to the State Survey Agency (SSA), the injury was not reported as required. The resident involved had significant medical conditions, including bilateral primary osteoarthritis of the hip, age-related osteoporosis, schizoaffective disorder, vascular dementia, muscle weakness, lack of coordination, and severe cognitive impairment. The resident was at risk for falls and complications related to his diagnoses. Staff first noticed the discoloration and pain during routine care and subsequently ordered a stat x-ray, which revealed a right proximal femoral fracture. The resident was then transferred to the hospital for further evaluation and management. Throughout the process, staff interviews confirmed that the source of the injury was unknown and met the criteria for an injury of unknown origin. Despite facility policy and regulatory requirements mandating immediate reporting of such injuries, the DON, ADON, and other staff did not notify the SSA within the required timeframe. Interviews revealed that staff were aware of the importance of reporting injuries of unknown origin but failed to do so. The facility's in-service records also showed no recent training related to reporting injuries of unknown origin. The administrator stated she was not informed of the injury and only learned of it during the surveyor's interview.
Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, for residents who required such interventions. One resident, who was admitted with a tracheostomy and a history of acute respiratory failure, did not have physician orders in place for trach care or suctioning since admission. Nursing staff did not perform regular tracheostomy care, citing discomfort and lack of training, and instead allowed the resident to perform his own trach care without supervision or documented competency. The resident was observed reusing disposable cannulas and cleaning them in non-sterile conditions, and his responsible party reported having to bring supplies from home. The resident was later hospitalized and diagnosed with pneumonia after experiencing respiratory distress and low oxygen saturation. Another resident with a tracheostomy and severe cognitive impairment also did not receive trach care and suctioning according to professional standards. Observations revealed that a nurse performed trach care without following infection control protocols, such as proper hand hygiene, use of sterile equipment, and appropriate suctioning technique. The nurse also reported not receiving adequate training or periodic competency evaluations for trach care, and had difficulty locating necessary supplies. Multiple staff interviews confirmed gaps in training, lack of skill checks, and uncertainty about who was responsible for trach care education and oversight. Record reviews showed that the facility's policies required physician orders for trach care, adherence to sterile technique, and regular staff training and competency checks. However, these requirements were not met, as evidenced by the absence of orders, improper care practices, and lack of documentation of staff competencies. The failures were identified as placing residents at risk for infection, respiratory distress, and other complications, and resulted in the identification of an Immediate Jeopardy situation by surveyors.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident with chronic pain and multiple complex medical conditions, including acute respiratory failure, tracheostomy status, dysphagia, chronic pain, and end-stage renal disease. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, but the medication was not reordered in a timely manner, resulting in the resident running out of the medication and experiencing excruciating pain for two days. During this period, the resident repeatedly requested pain relief and ultimately requested to be sent to the emergency room due to unrelieved pain. The resident's responsible party reported that the resident was crying and in severe distress due to lack of effective pain control. Documentation failures were also identified, as the resident's medication administration record (MAR) did not match the narcotic count sheet for PRN Hydrocodone, raising concerns about accurate medication administration and record-keeping. Additionally, the facility did not consistently assess or document the effectiveness of PRN Hydrocodone after administration, as required by physician orders and facility policy. Interviews with nursing staff revealed that documentation was sometimes missed due to being busy, and that pain assessments following PRN administration were not consistently performed or recorded. The nurse practitioner and director of nursing both stated that they were not notified in a timely manner about the resident's medication running low, and that the order for PRN Hydrocodone was not appropriate for the resident's needs in the facility setting. The facility's policies required timely reordering of medications, accurate documentation, and follow-up assessment of pain management interventions, but these were not followed. These failures led to the identification of Immediate Jeopardy by surveyors, as the resident was left without effective pain management and required transfer to the hospital for pain control.
Failure to Ensure Competent Tracheostomy Care by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide safe and effective care for a resident with a tracheostomy. Direct observation revealed that a nurse performed tracheostomy care and suctioning without adhering to professional standards of practice, including failure to perform hand hygiene, improper use of gloves, use of non-sterile equipment, and not following required procedures for oxygenation and suctioning. The nurse did not clean the resident’s trach stoma or change saturated dressings, and did not check or adjust oxygen prior to or during the procedure. The resident was observed with excessive secretions, soiled dressings, and was visibly distressed during the care. Interviews with multiple nursing staff indicated a lack of adequate training and competency validation in tracheostomy care. Several nurses reported not receiving hands-on training, periodic evaluations, or instruction on the use of trach care equipment. One nurse stated she had only practiced on mannequins and would require supervision to perform the procedure on a resident. Another nurse reported not being familiar with the resident or the necessary equipment, and both nurses expressed the need for reeducation on trach care. The responsible director of nursing was unable to provide documentation of staff competency evaluations when requested. The facility’s own policies required sterile technique, hand hygiene, and specific steps for tracheostomy care and suctioning, which were not followed during the observed incident. The lack of staff training, competency checks, and adherence to policy resulted in an Immediate Jeopardy situation, as staff were not equipped to safely care for residents with tracheostomies. The deficiency was identified through direct observation, staff interviews, and review of facility records and policies.
Removal Plan
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need for dialysis.
- A Special Bulletin inservice with sign-in sheet. RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents.
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI and revised as needed, to sustain improvement. An adhoc QAPI was conducted via teleconference to update education plan and review of revisions. An adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A QAPI will be held to notify and discuss plan and new clinical capabilities with medical director.
Failure to Provide Required Written Discharge Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to two residents and their representatives regarding facility-initiated discharges, including the reasons for the move, the right to appeal, and the required contact information for the State Long-Term Care Ombudsman. In both cases, the residents and their families were not given written notice in a language and manner they understood, nor was the notice provided at least 30 days in advance as required. Additionally, the facility did not send a copy of the discharge notice to the Ombudsman for either resident. One resident, a male with a history of tracheostomy, cerebral infarction, and respiratory failure, was discharged to another skilled nursing facility. The resident's family reported receiving only a phone call from the social worker on the day of discharge, with no written notice or options for alternative placements. The family was not informed of the actual discharge date or the final destination, and there was confusion regarding which facility the resident was transferred to. Documentation in the electronic medical record did not include a discharge notice, and the family learned of the discharge after it had already occurred. Another resident, a female with hemiplegia, hemiparesis, cognitive communication deficit, and acute respiratory failure, was sent to an acute care hospital and subsequently not allowed to return to the facility. The family was informed by phone that the resident would not be readmitted due to staffing limitations, but did not receive written notice, information about the discharge location, or the resident's appeal rights. The facility's own policies required consultation with the resident or representative, provision of discharge details, and notification of the Ombudsman, none of which were followed in these cases.
Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for two residents who were being treated for pressure ulcers. For both individuals, physician orders for wound care were not followed on multiple consecutive days, as documented in the Treatment Administration Records (TARs). Specifically, wound care treatments ordered by the physician were not administered on four separate days for each resident, and these omissions were not documented or explained in the medical records. One resident, a male with diagnoses including acute congestive heart failure, obesity, asthma, and edema, was assessed as being at risk for pressure ulcers and had specific wound care orders in place. Despite these orders, the TARs showed that the prescribed wound care was not provided on several days. Similarly, a female resident with chronic obstructive pulmonary disease, muscle weakness, end-stage renal disease, hypertension, and a pressure ulcer also did not receive the ordered wound care on the same dates. Observations confirmed that, at the time of survey, there was no infection or worsening of wounds, but the required treatments had not been administered as ordered. Interviews with facility staff revealed confusion and lack of communication regarding responsibility for wound care, particularly in the absence of the wound nurse (WN). Nurses on duty sometimes assumed the WN would provide the care, resulting in missed treatments. The Assistant Director of Nursing (ADON) and other staff acknowledged the importance of adhering to physician orders and confirmed that the omissions occurred. Facility policies required documentation of all wound care provided, but the records did not reflect that the treatments were given as ordered.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a nurse failed to adhere to infection prevention and control protocols during tracheostomy care and suctioning for a resident with significant medical needs. The nurse did not perform hand hygiene before and after glove changes, and did not follow sterile technique while suctioning. Specifically, the nurse donned gloves without hand hygiene, used soiled gloves to access personal items, and repeatedly failed to sanitize hands between glove changes. The nurse also used non-sterile equipment and did not properly clean or change necessary items during the procedure. The resident involved was a male with a history of tracheostomy, acute and chronic respiratory failure with hypoxia, gastrostomy, congestive heart failure, cerebral infarction, and dysphagia. He required ongoing oxygen therapy, suctioning, and tracheostomy care, and was assessed as having severe cognitive impairment. Physician orders and care plans specified the need for regular trach care, suctioning, and monitoring for signs of infection, with clear instructions for maintaining sterility and hand hygiene. Facility policies reviewed by surveyors outlined the requirement for hand hygiene before and after resident contact, between glove changes, and after removing gloves, as well as the use of sterile technique for invasive procedures. During interviews, the nurse acknowledged awareness of hand hygiene protocols but cited lack of sanitizer in the room as a reason for non-compliance. The Director of Nursing confirmed expectations for staff to follow infection control policies, including proper hand hygiene and sterile technique during trach care.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Obtain and Document Orders for Colostomy and Dialysis Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive care plan, and residents' preferences for three residents. One resident with a history of spina bifida, epilepsy, muscle weakness, and paraplegia was admitted with a colostomy, but there were no physician orders in place for managing or maintaining the colostomy since admission. The resident's care plan addressed bowel incontinence and skin integrity but did not include specific interventions for colostomy care, and the physician orders lacked any direction for colostomy management. Additionally, two residents with chronic kidney disease and other comorbidities required regular dialysis treatments. Although their care plans and assessments indicated the need for dialysis, there were no physician orders specifying the days on which dialysis was to be provided, despite both residents attending dialysis sessions on a set schedule. Interviews with facility staff, including the DON, RN, and ADON, confirmed that orders for colostomy care and dialysis schedules were expected but missing, and that the absence of such orders could result in missed care.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that signage indicating the need for personal protective equipment (PPE) was missing from the doors of four residents who had conditions such as open wounds, indwelling catheters, and pressure ulcers. Additionally, PPE bins were not present at these residents' doors, and staff were not consistently informed or aware of which residents required EBP. Staff interviews revealed a lack of understanding regarding EBP, with some CNAs stating they had never been instructed to wear gowns for high-contact care or catheter care for these residents. Direct observations showed that staff, including the ADON, did not wear appropriate PPE such as gowns while performing high-contact care activities like wound care, dressing, and bathing for residents with open wounds or indwelling catheters. In one instance, the ADON performed wound care on a resident's left heel without changing gloves or performing hand hygiene after removing a soiled dressing, thereby contaminating the wound. The ADON also did not wear a gown during this procedure, and similar lapses were observed during care for other residents requiring EBP. Review of the facility's policies indicated that PPE should be used as needed during wound care, and that infection control policies were intended to prevent and manage transmission of diseases. However, the facility was unable to provide current hand hygiene and EBP policies when requested. Interviews with staff and management confirmed that there had been no recent in-service training on EBP, and that responsibilities for ensuring PPE availability and signage were unclear or not consistently followed. These failures were observed for residents with significant medical needs, including chronic wounds, indwelling catheters, and other conditions requiring strict infection control measures.
Delayed Catheter Reinsertion and Inadequate Bladder Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to promptly reinsert a foley catheter for a female resident with multiple sclerosis, neuromuscular dysfunction of the bladder, paralytic syndrome, and overactive bladder. The resident's care plan and physician orders indicated the need for an indwelling catheter due to neurogenic bladder, with instructions to maintain and change the catheter as needed. On the morning in question, the resident's catheter was found to have come out, and the certified nursing assistant (CNA) notified the RN. Despite the resident expressing discomfort and a preference for the catheter to be reinserted, the RN delayed replacement for over eight hours, only reinserting the catheter in the afternoon after being prompted by the Director of Nursing (DON). Throughout the day, the resident was unable to sense when she was voiding, which caused her distress. Interviews with staff confirmed that the RN was aware of the situation but chose to postpone the procedure, and the nurse practitioner (NP) stated that such a delay could lead to urinary retention and a distended bladder. The facility was unable to provide a catheter care policy when requested. The failure to provide timely catheter care and adhere to physician orders constituted a deficiency in ensuring appropriate treatment and services to prevent urinary tract infections for the resident.
Failure to Notify Physician and Responsible Party of Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's physician and responsible party of a significant change in the resident's condition. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a notable decline over several days. Staff observed that he was no longer getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely documentation or notification to the nurse practitioner or responsible party regarding his altered status. Multiple staff interviews revealed that the resident's decline was apparent for several days, with increased lethargy, decreased participation in meals, and a cessation of his usual smoking routine. Some staff members noted the changes but did not consistently communicate them to the nursing team or document them in the medical record. The resident's responsible party was not informed of these changes and only became aware of the situation after visiting and finding the resident unresponsive and in bed, which was a significant deviation from his baseline behavior. The lack of prompt notification and documentation led to a delay in medical intervention. The resident was eventually transferred to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed in this case, resulting in the identification of an Immediate Jeopardy situation.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. The resident, an older male with a history of stroke, dementia, chronic pain, and nicotine dependence, experienced a significant change in condition that was not promptly recognized, addressed, or documented by staff. Over several days, the resident became increasingly lethargic, stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. Despite these changes, there was no timely follow-up or documentation regarding his post-fall status, pain, lethargy, or decreased functional abilities. Multiple staff interviews revealed that the resident's decline was observed by CNAs and nurses, including his staying in bed, not eating independently, and not smoking as usual. Some staff noted the changes but did not consistently notify the nurse or document the observations. Nurses who were aware of the changes did not escalate the concerns or notify the nurse practitioner (NP) or physician in a timely manner. The resident's responsible party was also not informed of the changes until after a care plan meeting, at which point the resident was found to be difficult to arouse and not at his baseline. The resident was eventually assessed as febrile, hypertensive, and unresponsive, leading to his transfer to the hospital, where he was diagnosed with possible aspiration pneumonia, a urinary tract infection, and a left femur fracture. The facility's policy required prompt notification of significant changes in a resident's condition to the physician and responsible party, but this protocol was not followed. The failure to recognize and act upon the resident's change in condition resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Maintain Safe and Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven residents by not keeping temperatures within the required range of 71 to 81 degrees Fahrenheit on two halls. Multiple residents reported that the air conditioning had not been working for at least two weeks, with some stating it had been out for up to three months. Observations confirmed that room and hallway temperatures repeatedly exceeded 81 degrees, with thermostat readings as high as 83 degrees. Several residents were provided with window air conditioning units or fans, but not all rooms had these, and some residents continued to experience discomfort due to heat. Maintenance logs and staff interviews indicated that complaints about room temperatures and requests for fans or air conditioning units had been made over several weeks, but not all were addressed promptly. Residents affected by the heat had various medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, heart failure, vascular dementia, and other serious health issues. Some care plans specifically included interventions to avoid exposure to extreme heat or cold, and to encourage adequate hydration. Despite these documented needs, residents reported feeling excessively hot, sweating, and in some cases, needing to move to cooler areas of the facility. Observations showed that not all residents had access to fans or functioning air conditioning, and some staff acknowledged that complaints had been made but not always acted upon. Interviews with facility staff and maintenance personnel revealed a lack of consistent monitoring and documentation of room temperatures, especially during periods when the central air conditioning was not functioning. The maintenance supervisor and administrator provided conflicting accounts regarding the duration and extent of the air conditioning failure. Maintenance logs showed delayed responses to requests for cooling equipment, and the facility's emergency preparedness plan, which included procedures for heat alerts and relocating residents, was not fully implemented. The air conditioning repair company confirmed that repairs could have been completed sooner if requested, but delays in obtaining quotes and authorizations contributed to the prolonged period of inadequate temperature control.
Failure to Provide Timely Behavioral Health Services and Protect Residents from Harm
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder and a history of aggressive behaviors received timely and necessary behavioral health care and services. Despite physician orders for psychiatric evaluation and management issued on two separate occasions, there was a significant delay in the resident being seen by psychiatric services. The resident exhibited escalating behaviors, including yelling, threatening, and physical aggression towards staff and other residents, which were documented in progress notes. The care plan included interventions for managing mood and behaviors, but these were not effectively implemented, and the resident did not receive psychological therapy as indicated in the MDS assessment. The resident's aggressive behaviors culminated in an incident where she scratched another resident with her fingernails during an outburst, resulting in injuries to the other resident's thigh. Documentation showed that the resident had a pattern of verbal and physical aggression, including threats with utensils and physical altercations. Staff interviews confirmed that the resident had ongoing behavioral issues since admission, and there was a lack of timely psychiatric intervention despite multiple referrals and physician orders. The delay was attributed to issues with the psychiatric service provider, including staff turnover and insurance problems, but there was no evidence of follow-up or alternative arrangements to ensure the resident's behavioral health needs were met. The other resident involved in the altercation had moderate cognitive impairment and required substantial assistance with activities of daily living. He sustained injuries as a result of the incident and expressed dissatisfaction with his care following the altercation. The facility's failure to implement behavioral health interventions and protect residents from harm was further evidenced by the lack of documentation of behavioral monitoring and the absence of timely psychiatric evaluation, despite clear indications and orders for such services.
Removal Plan
- Resident #1 was assessed and noted to be stable.
- An audit of Resident #1's current list of medications was performed by the Administrator to ensure all current medications were delivered and available in the facility.
- Resident #1 will be seen by Psych services for follow up and intervention (personal safety).
- Resident #1's care plan was updated with current psych diagnosis and interventions as well as specific behaviors and interventions.
- One on one monitoring has been placed for Resident #1 when near other residents until stable per psych NP recommendation or transfer out of the facility.
- Resident #2 was assessed after the event involving Resident #1, revealing no signs of distress or emotional agitation.
- Training of staff and audits of all residents identified as in need of behavioral health services as well as abuse and neglect were initiated by the Administrator.
- A spreadsheet was created with the identification of the services and if services were needed.
- The facility is verifying comprehension on staff training by following up after education based on a random selection.
- Staff will not be allowed to work their shifts until this Inservice and training has been completed.
- The Administrator will be responsible for the direct Inservice of her staff.
- All residents who have diagnoses or demonstrated signs of behavioral health concerns have the potential to be impacted by this deficient practice.
- The Administrator is directing the review of all residents with Behavioral Health diagnoses to identify unmet behavioral or psychiatric needs.
- All open psychiatric referrals were verified and re-submitted or scheduled.
- Review of all residents with Behavioral Health Diagnosis was started and completed by DON, ADON, Administrator.
- Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Responsible: DON, Admin, Social Worker.
- A review of their medications will be completed as well. The Psychiatrist will assist with any referrals or review of concerns that were identified with this audit.
- A review is scheduled for the Psychiatrist and Attending Physician on the medications as it relates to any current behaviors or events since the last Dose Reduction Review.
- The Regional Director of Operations has educated the Administrator, DON and ADON on behavioral care and services for the residents for the facility and comprehension will be verified at this same time.
- The administrator has created an audit tool to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders on behavioral health matters.
- Audits will be conducted by the DON daily for two weeks, weekly for two weeks and monthly for two months.
- A spreadsheet was created for the audit to be conducted and documented.
- Any negative findings will be reported to the administrator for immediate correction.
- The Medical Director was notified of the deficiency (F740) and an Ad-Hoc QAPI meeting was held to discuss the findings.
- All findings will be reported to the QAPI team for QAPI.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, or misappropriation were reported immediately to the State Survey Agency, as required. Specifically, an incident occurred in which one resident grabbed another resident's walker and pushed it, causing the second resident to fall and sustain a large skin tear on his forearm. This event was documented in progress notes and reported internally to the Director of Nursing (DON) and Nurse Practitioner (NP), but was not reported to the State Survey Agency within the required timeframe. Resident records show that the injured resident had a history of thrombocytopenia, muscle weakness, recurrent falls, chronic kidney disease, and alcoholic cirrhosis, and required a walker for mobility. The resident's care plan included interventions to prevent falls, and wound care orders were in place following the incident. The resident who caused the fall had diagnoses including encephalopathy, cognitive communication deficit, Alzheimer's disease, and unspecified dementia, with documented behavioral issues and a care plan addressing potential for verbal and physical aggression. Interviews with staff revealed that the incident was reported internally but not externally, as the administrator did not believe the event constituted abuse due to a perceived lack of malicious intent. Facility policy required immediate reporting of all suspected or substantiated incidents of abuse, including resident-to-resident abuse, to the appropriate state agencies, but this protocol was not followed in this case.
Failure to Notify Physician of Missed Medications Due to Resident Absence
Penalty
Summary
The facility failed to immediately notify a resident's physician or nurse practitioner when multiple doses of prescribed medications were missed due to the resident being out on pass. The resident, who had diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have missed several doses of critical medications such as aspirin, divalproex, doxepin, haloperidol, folic acid, multivitamin, and metoprolol over several days when she was away from the facility. Medication Administration Records (MAR) indicated these missed doses, but there was no documentation that the physician or nurse practitioner was notified upon the resident's return. Interviews with nursing staff revealed inconsistent practices regarding notification of missed medications. Some staff stated that they would notify the nurse practitioner or physician depending on the number of missed doses, while others indicated that the expectation was to always notify and document such events in the progress notes. However, review of the resident's progress notes confirmed that no such notifications or documentation occurred for the missed medications during the relevant period. The nurse practitioner also confirmed that he was not informed about the missed doses and emphasized the importance of being notified to provide appropriate recommendations. Further review showed that the facility's policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications. Despite this, there was no evidence of staff training on this requirement during the period in question, and staff interviews indicated a lack of clarity and consistency in following the policy. The deficiency was identified through record review and staff interviews, which confirmed the failure to notify the physician or nurse practitioner as required.
Failure to Ensure Proper Administration and Notification for Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for a resident. The resident, a woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had physician orders for several medications including aspirin, doxepin, divalproex, haloperidol, folic acid, multivitamin, and metoprolol. Review of the medication administration record (MAR) showed that multiple doses of these medications were missed on several days, with the MAR indicating the resident was 'away from the facility' during those times. The resident frequently went out on pass, sometimes overnight, and staff interviews revealed that when a resident was out during medication times, the MAR was marked accordingly. However, there was inconsistency in notifying the nurse practitioner (NP) or physician about missed medications, and documentation of such notifications was lacking. Staff interviews indicated that while some nurses believed they should notify the NP or physician and document it in the progress notes, this was not consistently done. The NP confirmed that he was not informed about the resident missing several days of medications and emphasized the importance of such notifications for clinical decision-making. Facility policy required prompt notification of the physician for changes in a resident's condition or status, including refusal or missed medications, and documentation of such notifications. Despite this, the review found no evidence that the NP or MD was contacted when the resident returned after missing medications, nor was there documentation in the progress notes. The failure to follow established procedures for medication administration and notification led to the deficiency.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly assist residents in obtaining routine dental services, resulting in unmet dental needs for three residents. For one resident, physician orders indicated a referral to the dentist for a dental exam due to complaints of tooth and gum pain, but there was no documentation of a dental exam or follow-up in the progress notes, and the resident reported not having seen a dentist in over five years despite ongoing dental issues. Another resident had a physician order for denture placement and expressed a desire for new dentures, but there was no evidence that the referral was made within three days or that the resident was seen by a dentist, even though the resident reported discomfort from a broken tooth and requested denture adjustment. A third resident expressed the need for a dental cleaning and had not seen a dentist in over a year, despite a care plan indicating poor dental condition and a request for dentures. There was no documentation of a dental referral or appointment for this resident, and the last recorded dental visit was over a year prior, during which a new cavity was noted. Interviews with staff revealed confusion regarding responsibility for making dental referrals, with some believing it was the nurse's responsibility and others indicating it was the social worker's role. The social worker, who had started six months prior, was unclear about the previous dental provider and had only recently secured a new dental contract, but as of the time of the survey, no dental visits had occurred under the new arrangement. Facility leadership, including the DON and administrator, confirmed that social services was responsible for dental appointments and acknowledged delays in securing a dental contract and arranging dental visits. The facility's policy required routine and emergency dental services to be available in accordance with residents' assessments and care plans, with social services responsible for assisting with appointments. However, the lack of timely referrals and absence of dental services for the residents reviewed demonstrated a failure to meet these requirements.
Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not reflect the resident's history of falls, despite documented incidents on three separate occasions. The resident, an older woman with multiple diagnoses including apraxia, atherosclerotic heart disease, cerebral aneurysm, paranoid schizophrenia, bipolar disorder, and anxiety disorder, was noted to have no cognitive impairment and was independent with transfers. However, her care plan did not include any mention of falls, even though incident reports documented both witnessed and unwitnessed falls without injury. Interviews with facility staff, including LVNs, the MDS RN, the DON, and the ADM, confirmed that falls should have been included in the resident's care plan and that it is the responsibility of various staff members to update the care plan with such information. The facility's policy requires that care plans be individualized, comprehensive, and revised as the resident's condition changes, incorporating measurable objectives and timetables. Despite these requirements and the staff's understanding of the process, the care plan was not updated to reflect the resident's falls, resulting in a deficiency.
Failure to Maintain Safe Wheelchair Conditions for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as evidenced by the inadequate maintenance of their wheelchairs. Resident #1, a male with a history of osteomyelitis and an above-the-knee amputation, reported that his wheelchair, which was from the 1960s, could not lock properly. Despite informing the social worker and therapy staff about the issue, no maintenance work order was recorded for his wheelchair. Interviews with the physical therapy assistant and occupational therapist confirmed that the wheelchair had a loose lock and was not safe for Resident #1, who was an amputee and required a stable wheelchair for safe transfers. Resident #2, a male with cerebral infarction, visual impairments, and a history of falls, also experienced issues with his wheelchair brakes. Although a work order was documented in the maintenance logbook, it was mistakenly marked as completed without the necessary repairs being made. During an observation, Resident #2 demonstrated that his wheelchair's left wheel did not lock, posing a risk of falling when he attempted to stand. The maintenance director acknowledged the error and expressed concern for Resident #2's safety, emphasizing that wheelchair repairs should be prioritized as emergencies. The facility's policies on maintenance and resident rights were not adhered to, as evidenced by the failure to address the residents' grievances and ensure their safety. The maintenance department's oversight in marking incomplete work orders as done and the lack of timely repairs for critical equipment like wheelchairs contributed to an unsafe environment for the residents. Interviews with staff, including the maintenance director and CNA, highlighted the communication breakdown and procedural lapses that led to the deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by two specific incidents involving two residents. In the first incident, a certified nursing assistant (CNA) was observed using his phone during peri care for a female resident with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness. The resident's family member provided video footage showing the CNA on his phone while the resident's lower body was exposed, which lasted for two minutes before the CNA resumed care. This incident was reported to the Director of Nursing (DON), who confirmed the CNA was texting during the care process. In the second incident, a male resident with paraplegia and a suprapubic catheter was observed moving through the facility without a privacy bag covering his catheter bag. Although the resident stated he was not bothered by the lack of a privacy bag, the facility's policy requires catheter bags to be covered to prevent potential embarrassment. The lack of a privacy bag was noted by a Licensed Vocational Nurse (LVN) only after it was pointed out, indicating a lapse in adherence to the facility's resident rights policy, which mandates treating all residents with kindness, respect, and dignity.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a gastrostomy tube had her head of bed (HOB) elevated at least 30 degrees, as required to prevent complications such as aspiration. On the evening of February 17, 2025, a licensed vocational nurse (LVN) connected the resident's feeding tube but did not elevate the HOB, leaving the resident lying flat. This oversight was captured on video footage provided by the resident's family member, who later found the resident struggling to breathe with foam around her mouth. The resident, a female with a history of dysphagia, cerebral infarction, vascular dementia, and muscle weakness, was on a continuous feeding regimen of Nepro at 50 ml/hr for 22 hours a day. Her care plan specified the need for HOB elevation during and after feeding. Despite this, the LVN left the resident's room without adjusting the bed, and the family member had to intervene by elevating the bed and clearing the foam from the resident's mouth, which alleviated her breathing difficulties. Interviews with facility staff, including the Director of Nursing (DON) and the LVN involved, revealed a lack of awareness and communication regarding the incident. The DON acknowledged the risk of aspiration if the HOB is not elevated and stated that all staff are responsible for ensuring proper positioning during tube feeding. The facility's policy and external guidelines both emphasize the importance of maintaining HOB elevation to prevent aspiration, yet this protocol was not followed, leading to the resident's distressing experience.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for four residents within 48 hours of their admission, as required. This deficiency was identified through interviews and record reviews, which revealed that Residents #3, #4, #5, and #6 did not have baseline care plans completed. These residents had various medical conditions, including respiratory failure, end-stage renal disease, diabetes, pressure ulcers, cognitive communication deficits, and more. The absence of baseline care plans could lead to a lack of continuity of care and miscommunication among staff, potentially affecting the residents' immediate care needs. Interviews with facility staff, including the social worker, Director of Nursing (DON), and Administrator, highlighted that the facility was behind on care plans due to recent changes in management and staffing shortages. The social worker, who had been at the facility for only three weeks, acknowledged the backlog of care plans and the importance of having them completed to ensure proper resident care. The DON and Administrator also confirmed the delay in care plan completion and the potential for miscommunication among staff without them. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not adhered to for the residents in question.
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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.
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Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arbour At Westminster Manor | 2.3 mi | ★★★★★ | 4 | 0 |
| Sage Park Austin | 2.3 mi | ★★★★★ | 0 | 0 |
| Sedona Trace Health And Wellness Center | 3.3 mi | ★★★★★ | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation - North | 4.4 mi | ★★★★★ | 11 | 2 |
| Gracy Woods Nursing Center | 4.5 mi | — | 21 | 1 |
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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.