Harmony Care At Giddings

Penalty

Fine: $19,120

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, resulting in an elopement from a secured unit. The resident was an elderly male with schizophrenia, Alzheimer’s disease, anxiety disorder, and recurrent major depressive disorder. His most recent MDS showed a BIMS score of 2, indicating severe cognitive impairment, with documented hallucinations, delusions, and wandering behavior occurring 1–3 days during the look‑back period. His care plan and elopement assessment identified him as an elopement risk and noted poor safety awareness related to his Alzheimer’s disease and schizophrenia, and he resided on a secure unit due to this risk. On the night of the incident, the resident was on the secured unit lobby area in his wheelchair, with another resident on a couch nearby. LVN A, the charge nurse on duty for the 6:00 pm to 6:00 am shift, reported that at about 1:00 am she rounded on the secured unit and instructed CNA B, an agency CNA assigned to the secured unit, to sit close to the two residents in the lobby area to monitor them. Around 2:00 am, LVN A returned to the unit and noted that the resident was no longer sitting where she had last seen him. At approximately the same time, a police officer arrived at the facility and asked if they were missing a resident, describing a man in a yellow wheelchair matching the resident’s description. Interviews and written statements showed that CNA B had heard the secured unit door alarm sound about 20–30 minutes before police contact but did not notify LVN A or check outside the door. CNA B reported that when the alarm sounded, she went to the door, saw the other resident sitting on the couch near the door, and assumed that resident had triggered the alarm. She turned the alarm off, did not look outside, did not conduct or request a head count, and did not inform the charge nurse that the alarm had gone off. As a result, the resident was able to leave the secured unit through the lobby door without timely detection. The resident was later found by local law enforcement walking along a major state highway approximately 0.9 miles from the facility in the early morning hours and was returned to the facility, where assessment documented no apparent injuries and stable vital signs. The surveyors determined that this failure to respond appropriately to the door alarm and to follow elopement procedures constituted noncompliance at the level of Immediate Jeopardy (IJ) beginning on 02/23/2026 and ending on 02/25/2026. The noncompliance was identified as Past Noncompliance (PNC). The deficient practice was cited for failing to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents reviewed for accidents and hazards.

Removal Plan

• PD brought Resident #1 back to the facility
• Resident #1 was assessed head to toe and had no apparent injuries
• Resident #1 was placed on 1:1 monitoring
• Resident #1 and all other residents in the facility were reassessed for elopement risk
• Staff were in-serviced on elopement
• Staff participated in elopement drills twice since Resident #1's incident
• Door stoppers were placed on 2 of the secure unit doors
• The staffing Agency was notified of agency staff actions
• Maintenance checked alarms and door magnetic locks
• The MD was notified of the incident
• An Ad hoc was held

Penalty

Fine: $31,765

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from abuse when one cognitively impaired resident physically assaulted another with a plastic trash can, causing a scalp laceration that required three staples and a brief hospitalization. The aggressor was a 70-year-old man with dementia, schizophrenia, and Parkinson’s disease, who had a BIMS score of 7 indicating severe cognitive impairment. His care plan documented a history of inappropriate and physically aggressive behaviors, including a prior incident on 12/13/25 in which he allegedly kicked and punched another resident who had entered his room. Staff interviews and a psychiatric NP evaluation described him as withdrawn, territorial about his room, paranoid when others entered his space, and prone to aggression when other residents came near or into his room. The assaulted resident had severe cognitive impairment with a BIMS score of 0 and diagnoses including altered mental status, acute kidney failure, and thrombocytopenia. He resided on the secure unit due to elopement risk, need for reduced stimuli, and wandering. On the date of the incident, a CNA reported hearing commotion in the hall and then observing the aggressor holding a plastic trash can over the other resident’s head and hitting him multiple times. The CNA separated the residents, after which the aggressor returned to his room and closed the door, and the injured resident was escorted to the lobby. Hospital records documented a scalp contusion and laceration with three staples placed. Multiple staff and the psych NP reported that the aggressor routinely became upset or aggressive when other residents approached or entered his room, and that the injured resident frequently came to or attempted to enter that room, sometimes using the door to propel his wheelchair. Staff stated it was “normal” for the aggressor to get aggressive when residents wandered into his room, that he would push residents out, and that other residents were not cognitively able to recognize the threat of going near his doorway. The social worker and DON acknowledged that the aggressor’s need for personal space and his paranoid schizophrenia had led to repeated altercations and that these behaviors and triggers were not adequately addressed or updated in his care plan. The secure unit housed wandering residents, and staff reported trying to redirect residents away from the aggressor’s room but also stated that residents had a right to move about the unit. The facility’s own secured unit policy required individualized, person-centered care based on residents’ needs and behaviors, but interviews revealed gaps in dementia and mental health training and a lack of specific, implemented interventions to prevent resident-to-resident altercations related to the aggressor’s territorial behavior. The facility had placed the aggressor on the secured unit based on a physician’s order citing elopement risk, yet the only documented elopement risk assessment showed no verbal expressions of wanting to leave and no history of elopement. The social worker and the aggressor’s responsible party both indicated they did not view him as an elopement risk and instead emphasized his paranoid schizophrenia, history of theft at a prior facility, and desire to stay in his room to protect his belongings. Staff interviews showed uncertainty about why he was on the secure unit and highlighted that his primary issue was aggression when others approached his space. Despite known prior incidents and staff awareness that residents frequently wandered and forgot to avoid his door, the care plan and unit practices did not sufficiently address these known triggers, contributing to the resident-to-resident assault that resulted in injury. The interim administrator and DON acknowledged that interventions specific to the aggressor’s behaviors and triggers, such as measures to keep other residents from approaching his door, had been discussed but not implemented or incorporated into the care plan. Staff also reported that while there had been general in-services on resident-to-resident abuse, there was no specific training on managing this resident’s behaviors. The secured unit policy emphasized gathering history, preferences, and routines to tailor care, yet interviews and record reviews showed that the aggressor’s territoriality, paranoia, and history of altercations were not effectively translated into concrete, consistently applied interventions. This lack of effective, individualized behavioral management and environmental controls allowed a known pattern of aggression to culminate in the physical assault and injury of another resident.

Penalty

Fine: $31,765

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse and neglect for several residents. For one cognitively intact female resident with cerebral palsy, schizophrenia, and incontinence, the record shows she required maximal assistance for toileting and was always incontinent of bowel and bladder. She alleged that unknown staff at an unknown time did not perform pericare appropriately and left feces in her vaginal area. The provider investigation report documented her complaint but only referenced general staff in-services and safe surveys that predated the allegation, with no evidence of a new, allegation-specific in-service, no new safe surveys, and no documented new skin assessment during the investigation. A second resident, a severely cognitively impaired female with Parkinson’s disease and muscle wasting, was care planned as being at risk for falls. Nursing notes documented that she was found on her knees on the floor holding onto a table, assessed with no injuries, and returned to bed, with the physician and family notified. Later, her family reported that she had fallen and was left on the floor for over an hour. The provider investigation report again referenced only general in-services and safe surveys dated prior to the allegation, with no new in-services related to the specific incident, no formal skin assessment beyond a narrative note, and no safe surveys conducted with other residents. The DON stated she was unsure how long the resident was on the floor and confirmed that no new safe surveys or formal skin assessment were completed. A third resident, a severely cognitively impaired male with a cervical spinal cord injury and a stage 4 sacral pressure ulcer, alleged that around the time of his admission a female agency CNA placed a pillow over his face while providing care. The provider investigation report documented the allegation and referenced abuse monitoring and staff in-services, but the in-services and safe surveys cited were dated before the allegation and were not newly initiated for this event. The DON reported that she interviewed the resident but did not attempt to identify the alleged perpetrator, did not initiate new in-services or safe surveys, and acknowledged missing multiple elements in the investigation. The resident’s care plan contained no focus related to this allegation, and key assessments such as a new skin assessment, BIMS, and trauma assessment were delayed several days after the allegation, rather than completed on the day it was reported. The facility also failed to investigate an alleged resident-to-resident abuse incident involving two severely cognitively impaired male residents. One resident, with dementia, schizophrenia, and Parkinson’s disease, had a care plan focus for inappropriate behaviors and physical aggression, including a note that on a specific date he allegedly kicked and punched another resident who was on the ground after entering his room. Progress notes by an LVN documented that this resident was allegedly kicking and punching the other resident, who had wandered into his room. The other resident, who resided in a secure unit due to elopement risk and wandering, had severe cognitive impairment and multiple medical diagnoses including altered mental status, acute kidney failure, and thrombocytopenia. The LVN later stated he did not notify the Administrator, who was the abuse and neglect coordinator, about the incident, and the DON confirmed the event was not reported to the state and was not investigated as an allegation of physical abuse. Interviews with the DON and Administrator further established that the investigations for the first three residents were incomplete and did not meet facility expectations or policy requirements. The DON acknowledged that no new safe surveys were conducted for the first two residents, that no formal in-service specific to pericare or the fall allegation was provided, that no timely skin assessments were documented under the correct forms, and that she did not attempt to identify the alleged perpetrator in the pillow incident. The Administrator, who started after these events, reviewed the investigations and stated they were not thorough, noting the absence of allegation-specific in-services, skills observations, resident interviews, timely assessments, and new safe surveys. The facility’s written policy on abuse, neglect, exploitation, and misappropriation requires immediate protection of residents, initiation of investigations, reporting of all alleged or suspected incidents, and retraining following incidents or identified trends, but the documented investigations and staff interviews show that these steps were not fully carried out for the cited allegations.

Penalty

Fine: $31,765

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident abuse incident to the administrator and appropriate state authorities as required by policy and regulation. On 12/13/25, a nurse (LVN A) documented in the electronic health record that one resident (Resident #4) was allegedly kicking and punching another resident (Resident #5), who was on the ground after entering Resident #4’s room. LVN A assessed both residents and noted no injuries, completed a facility incident report, and entered a progress note in Resident #4’s record, but did not notify the Administrator, DON, or abuse coordinator of the allegation. The incident was therefore not reported to Health and Human Services as an allegation of abuse. Resident #4 was a 70-year-old man with dementia, schizophrenia, and Parkinson’s disease, with a BIMS score of 7 indicating severe cognitive impairment. His care plan included a focus on inappropriate behaviors and physical aggression, noting that on 12/13/25 he allegedly kicked and punched another resident who had entered his room. Resident #5 was a male resident with altered mental status, acute kidney failure, and thrombocytopenia, with a BIMS score of 0 indicating severe cognitive issues, and a care plan focus on residing in a secure unit due to elopement risk, need for reduced stimuli, and wandering. The alleged altercation occurred when Resident #5 wandered into Resident #4’s room, and Resident #4 became upset. Multiple staff interviews confirmed that the incident met the facility’s definition of a reportable resident-to-resident altercation and that all staff had been trained to report abuse, neglect, and exploitation immediately to the Administrator, who served as the abuse and neglect coordinator. LVN A acknowledged he did not inform the Administrator and stated he should have done so. The DON and social worker both stated that the incident should have been reported to the State as an allegation of abuse, and the Interim Administrator stated that leadership was not made aware of the incident and therefore no investigation or state report was initiated. Review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention, Reporting, and Investigation Policy, dated 01/2026, showed a requirement to immediately protect residents, initiate investigations, and report all alleged or suspected incidents as required by Texas HHSC and CMS, which was not followed in this case.

Penalty

Fine: $89,540

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as to ensure proper investigation and reporting of such allegations. Specifically, the facility did not ensure the safety of two residents after they made serious allegations against each other and a staff member. One resident, who was paralyzed and required significant assistance with activities of daily living, alleged that the Administrator (ADM) harassed, bullied, and picked on him. Despite this, there was no documentation of the allegation in the resident's records, no investigation was initiated, and no interventions were implemented to ensure his safety. Staff interviews revealed confusion about the process for handling such allegations, and the ADM, who was also the abuse and neglect coordinator, stated he was not aware of the allegation and had not investigated it. Another resident, who was cognitively intact but had a history of manipulative and impulsive behaviors, alleged that the first resident threatened her with sexual violence. She called the police non-emergency line, and law enforcement responded, instructing both residents to stay away from each other. However, the facility did not document the incident, offer a room change, or implement any interventions to separate the residents or ensure their safety. Both residents continued to reside on the same hallway, and staff did not monitor or document any follow-up actions related to the allegations. Progress notes, assessments, and the facility's incident log contained no entries regarding these events. Interviews with various staff members, including the DON, HR, SW, and CNAs, revealed a lack of clarity and training regarding the reporting and investigation of abuse, neglect, and exploitation (ANE). Staff consistently identified the ADM as the abuse and neglect coordinator responsible for reporting and investigating ANE, but there was no evidence that the required steps were taken in response to the allegations. The facility also failed to remove the alleged perpetrator from the environment upon notification of the allegations, and there was no documentation of any investigation or reporting to the appropriate authorities. This lack of action and documentation placed residents at risk of further abuse, neglect, or harm.

Penalty

Fine: $89,540

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was not discharged when exercising the right to appeal a discharge notice, and did not provide for a safe and appropriate discharge environment. The resident, who was cognitively intact and had significant medical needs including vertebra osteomyelitis, stage 3 and 4 pressure ulcers, neuromuscular bladder dysfunction, paraplegia, protein-calorie malnutrition, cellulitis, and sepsis, was issued an immediate discharge notice following allegations of making threats toward staff. The discharge notice did not specify an address for discharge, and the resident was served the notice in the presence of police officers, with a no trespass order also issued. The resident declined offers for a hotel stay and hospital transport, stating he could not care for himself and needed ongoing care and services. Despite this, the facility proceeded with the discharge, and the resident reported having nowhere to go, ultimately sleeping in his truck and not receiving necessary wound care, meals, or ADL assistance after discharge. Interviews with facility staff revealed inconsistencies and lack of clarity regarding the alleged threats, with some staff unable to recall details or confirm the nature of the threats. Documentation and incident logs did not consistently reflect the reported behavioral incidents leading to the discharge. The facility did not implement additional interventions such as 1:1 supervision or behavioral services prior to discharge, and there was no evidence of a completed discharge planning review or confirmation of a safe discharge location. The resident's hospice provider was notified, but there was no confirmation that hospice services continued after discharge or that the resident had access to necessary care and supplies. The facility also failed to allow the resident to remain in the facility during the appeal process, as required, citing immediate jeopardy due to the alleged threats. The resident and some staff disputed the severity and veracity of the threats, and the resident denied making specific threats to shoot staff. The facility's actions resulted in the resident being left without a safe discharge plan or continued care, despite his complex medical needs and dependence on staff for assistance with activities of daily living and wound care.

Penalty

Fine: $89,540

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a resident with proper notice prior to discharge, specifically omitting the address of the discharge location on the notice and not notifying the resident as soon as practicable before the discharge occurred. The resident, who was cognitively intact and had significant medical needs including vertebra osteomyelitis, stage 3 and 4 pressure ulcers, neuromuscular bladder dysfunction, paraplegia, protein-calorie malnutrition, cellulitis, and sepsis, was served with an immediate discharge notice due to alleged threats made toward staff and administration. The discharge notice did not include the required address of the discharge location, and the resident was not given adequate time or information to prepare for the discharge. Interviews and record reviews revealed that the resident was offered a hotel stay and transportation to a hospital, both of which he declined, but he was not provided with an alternative placement or a clear discharge plan. The resident reported having nowhere to go after discharge and ultimately slept in his truck, missing necessary wound care, ADL care, and meals. Staff interviews confirmed that the discharge planning review was incomplete, and there was no documentation of the alleged behavioral incidents leading to the discharge in the resident's progress notes or the facility's incident log. The resident's care plan indicated a high level of dependence on staff for daily care and medical management, yet these needs were not addressed in the discharge process. The facility also failed to document or communicate the location to which the resident was being discharged, as required by regulation. The discharge was executed in the presence of police officers, and the resident was served with a no trespass order. Despite the resident's request to appeal the discharge and remain in the facility during the appeal process, the facility did not allow him to stay, citing immediate jeopardy. The lack of proper notification and discharge planning resulted in the resident being left without a safe or appropriate discharge destination, and the facility did not ensure continuity of care or services post-discharge.

Penalty

Fine: $89,540

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident with complex medical needs. The resident, who was cognitively intact and had significant medical diagnoses including vertebra osteomyelitis, stage 3 and 4 pressure ulcers, neuromuscular bladder dysfunction, paraplegia, protein-calorie malnutrition, cellulitis, and sepsis, was subject to an immediate discharge following allegations of making credible threats of violence toward staff, including a threat to shoot the administrator. The discharge process was initiated without a thorough investigation into the validity of the witness statements regarding the alleged threats. Documentation and interviews revealed inconsistencies and a lack of clarity about the nature and timing of the threats, as well as insufficient documentation in the resident's progress notes and incident logs related to the alleged incidents. The facility did not take immediate action to ensure the safety of all residents when the alleged credible threat was reported. There was a delay in notifying law enforcement, and the resident was not placed on 1:1 supervision or provided with other interventions during the period between the alleged threat and the discharge. Staff interviews indicated confusion about the process for handling such threats, and there was no clear evidence that behavioral or psychiatric services were offered or that the resident's care plan was updated to address the situation. The discharge notice provided to the resident did not include an address for discharge, and alternative placement options were limited to a hotel stay, which the resident declined due to inability to self-care. Following the immediate discharge, the resident, who required assistance with activities of daily living and wound care, was left without a safe and proper discharge plan. The resident reported having nowhere to go, ultimately sleeping in his truck and not receiving necessary care, meals, or wound care supplies. Facility leadership and staff were unable to confirm the resident's whereabouts or continuity of care post-discharge. The discharge planning review was incomplete, and there was no evidence of follow-up or due diligence to ensure the resident's safety and ongoing care after leaving the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the period of October 1, 2024, to December 31, 2024, as required by federal regulations. The missing submission included essential details such as the category of work for each direct care staff member, including whether individuals were registered nurses, licensed practical nurses, certified nursing assistants, therapists, or other specified medical personnel. This deficiency was identified through record review, which showed no Payroll Based Journal (PBJ) data was submitted for the specified quarter, and was confirmed during an interview with the Corporate Nurse. During the interview, the Corporate Nurse acknowledged awareness of the missing PBJ submission and stated uncertainty regarding the reason for the failure. She indicated that the previous Administrator, who resigned on July 1, 2025, did not ensure the required data was submitted. The facility's policy on reporting direct care staffing information outlines the requirement for timely and accurate electronic submission of staffing data to CMS, but this process was not followed for the quarter in question.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or observed events are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that one of two facility garbage containers in the kitchen did not have a lid attached or placed on it, despite containing waste. This observation was made during a facility inspection. Interviews with the Dietary Supervisor and a Dietary Aide confirmed that facility policy requires trash cans to be covered at all times except during use, and both staff members acknowledged that leaving trash cans uncovered could lead to contamination. A review of the facility's Dietary Services Policies and Procedures for Waste Control and Disposal also confirmed the requirement for trash cans to remain covered except when in use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed several mouse droppings on the bottom shelf in the facility's kitchen food storage room during an inspection. The Dietary Supervisor confirmed that the droppings appeared to be from mice and stated that the maintenance department was responsible for pest control. The Maintenance Supervisor, who began working at the facility in early June, reported that while he had not personally seen pests, staff members had informed him of mouse sightings. He also indicated that pest control services had visited the facility twice in the previous month to perform extermination services, and he could provide documentation of these visits. A review of facility records showed that the food storage policy required storage areas to be free from rodent and insect infestation and to be treated for pests on a regular schedule. Pest control service inspection reports confirmed recent treatments for rodents, roaches, spiders, and ants. Despite these measures and policies, the presence of mouse droppings in the food storage area indicated that the facility failed to maintain an effective pest control program to keep the area free of pests.

Penalty

Fine: $113,96027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a male resident with a history of autistic disorder, hypertension, urinary retention, recurrent urinary tract infections (UTIs), and diabetes mellitus type II did not receive appropriate catheter care as ordered. The resident had an indwelling Foley catheter with physician orders specifying monthly changes and routine catheter care every shift. Documentation showed that the Foley catheter was not changed as ordered on two consecutive months, despite being signed off as completed by medication aides (MAs) who later admitted they did not perform the task and that it was outside their scope of practice. The care plan for the resident did not include interventions for catheter care, diabetes, or hypertension at the time of the incident. The resident was subsequently transferred to the emergency room after staff noted fever, lethargy, decreased urine output, and low blood pressure. Hospital records indicated the resident was diagnosed with a urinary tract infection, possible sepsis, acute kidney injury, and pneumonia. The Foley catheter was found to have brown urine with pus and was replaced in the emergency room. Interviews with staff revealed a lack of clarity regarding responsibilities for catheter changes, with MAs signing off on tasks they did not perform and failing to notify licensed nurses of the outstanding orders. The DON confirmed that MAs were not permitted to change Foley catheters and that the resident's catheter change orders were not followed as required. Further review of facility documentation and interviews with the nurse practitioner and medical director highlighted discrepancies in the understanding and implementation of catheter care orders. The medical director expressed disagreement with the monthly change order, but the facility had not clarified or updated the order prior to the incident. The lack of proper documentation, failure to follow physician orders, and absence of a comprehensive care plan for catheter management contributed to the resident's hospitalization and the identification of an Immediate Jeopardy situation by surveyors.

Penalty

Fine: $113,96027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services that ensured the accurate acquisition, receipt, dispensing, and administration of all drugs and biologicals to meet the needs of a resident. Specifically, the facility did not carry out hospital discharge orders for insulin administration to control blood glucose for a resident with a diagnosis of uncontrolled type 2 diabetes mellitus. The resident was admitted with a history of diabetes, hypertension, urinary retention, and autistic disorder, and had clear hospital discharge instructions for insulin NPH Hum/Reg 70/30 to be administered subcutaneously before breakfast and dinner, as well as orders for blood glucose monitoring. Upon review, it was found that the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any orders for insulin or blood sugar checks for the months following admission. Multiple staff interviews revealed a lack of awareness regarding the resident's need for insulin or glucose monitoring. The Director of Nursing (DON) acknowledged not entering the resident's orders into the electronic medical record and did not follow up to ensure hospital records were received. The nurse practitioner (NP) and medical director also failed to verify that the insulin orders were implemented, and the NP did not review the MAR/TAR during visits. The resident subsequently developed severe hyperglycemia and diabetic ketoacidosis (DKA), requiring transfer to the emergency room. The facility's own policies required thorough medication reconciliation upon admission, including review of hospital discharge summaries and communication with referring providers to resolve discrepancies. However, these procedures were not followed, resulting in the omission of critical insulin therapy and glucose monitoring for the resident. Staff interviews and documentation confirmed that the breakdown in communication and failure to implement discharge orders directly led to the resident's acute medical deterioration.

Penalty

Fine: $113,96027 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to develop a comprehensive, person-centered care plan for a male resident with multiple complex medical conditions, including autistic disorder, hypertension, urinary retention with an indwelling catheter, a history of urinary tract infections, and diabetes mellitus type II. The resident's admission Minimum Data Set (MDS) indicated severe cognitive impairment, short-term and long-term memory problems, and the need for special treatments such as oxygen therapy and anticoagulant medication. Despite these needs, the care plan initiated for the resident only addressed dietary needs and did not include plans for catheter care, diabetes management, oxygen therapy, anticoagulant use, or hypertension. Record reviews showed that the resident was prescribed multiple medications for hypertension, anticoagulation, and urinary retention, and had specific orders for catheter care and oxygen therapy. However, these critical aspects of care were not reflected in the resident's comprehensive care plan. Interviews with facility staff, including the DON, Interim Administrator, and MDS nurse, revealed a lack of clarity and follow-through regarding the timely completion of comprehensive care plans. The MDS nurse acknowledged that the comprehensive care plan for this resident was not completed after the assessment, stating it "fell through the cracks." The facility's own policy requires that a comprehensive, person-centered care plan be developed within seven days of the required MDS assessment and no more than 21 days after admission, including measurable objectives and timeframes for all identified needs. In this case, the policy was not followed, resulting in the resident not having a care plan that addressed all of his medical, nursing, and psychosocial needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and maintain an effective infection prevention and control program, specifically in relation to the management of COVID-19 cases among residents. One resident, who had a history of systemic lupus erythematosus, cognitive impairment, and respiratory issues, was sent to the hospital due to a change in condition and subsequently tested positive for COVID-19. Upon return to the facility, there was no evidence that the resident was placed in isolation, no signage was posted on the door to indicate the need for personal protective equipment (PPE), and staff did not consistently wear appropriate PPE when providing care. The resident's hospital records, which confirmed the COVID-19 diagnosis and recommended droplet precautions, were not immediately reviewed or made available to staff, resulting in a lack of communication and appropriate infection control measures. Additionally, the facility failed to remove the COVID-negative roommate from the shared room or test the roommate as required by infection control protocols. Interviews with staff, including LVNs, CNAs, and the DON, revealed confusion and lack of communication regarding the resident's COVID-19 status. Some staff were unaware of the positive test result, and others did not take action to isolate the resident or notify the appropriate parties. The facility also lacked current COVID-19 test kits, which prevented retesting and further complicated the response. The infection control logs did not reflect any COVID-19 cases during the relevant period, and staff reported not being in-serviced on COVID-19 protocols in the preceding 60 days. The facility's infection prevention and control policy required the identification and management of infections, implementation of isolation precautions, and staff education, but these procedures were not followed in this instance. The administrator and DON both acknowledged gaps in communication and documentation, including the failure to obtain and review hospital records in a timely manner. The lack of adherence to established infection control protocols and failure to isolate the COVID-positive resident or protect the roommate constituted a deficiency in the facility's infection prevention and control program.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's request to be assisted out of bed, which compromised her right to a dignified existence and self-determination. The resident, who has a history of hemiplegia, depression, and pain, expressed a desire to get out of bed and eat in the dining room with others. However, she was told by staff that they could not assist her due to the unavailability of a clean sling required for her transfer. This situation was observed on the morning of February 9, 2025, when the resident remained in bed eating breakfast alone, despite her preference to join others in the dining room. Interviews with staff revealed that the lack of a clean sling was a recurring issue, occurring approximately once a week. A CNA confirmed the inability to assist the resident due to the sling being in the laundry, while a laundry aide indicated that the sling had not yet been washed and was waiting to be air-dried. The facility administrator was unaware of the issue until after the observation and acknowledged that residents should not be denied the opportunity to get out of bed due to such logistical problems. The deficiency highlights a failure to ensure the resident's rights to self-determination and participation in activities of choice were respected.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately notify the responsible party of a resident when there was a significant change in the resident's physical and psychosocial status. Specifically, the facility did not inform the responsible party of two critical incidents involving the resident. The first incident occurred when the resident was hit by another resident, and the second incident involved the resident being sent to the emergency room after a fall, which resulted in increased confusion. These lapses in communication could potentially put residents at risk by not having their care needs and health changes communicated and addressed with their responsible party. The resident in question is an elderly female with Alzheimer's disease, cognitive communication deficit, and dementia, who was admitted to the facility with moderate cognitive impairment. The facility's records showed no documentation of the incident on the day the resident was hit, and although the resident was sent to the hospital after a fall, the responsible party was not notified. Interviews with staff revealed a breakdown in communication and assumptions that others had taken the necessary steps to notify the responsible party, which did not occur. The facility's policy requires that all incidents, accidents, or changes in a resident's condition be recorded and that family, physicians, or other staff be notified if indicated. However, in this case, the policy was not followed, as evidenced by the lack of documentation and notification to the responsible party. The Director of Nursing and other staff members were either unaware of the incidents or assumed that others had taken the necessary actions, leading to a failure in communication and documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of abuse involving two residents. On February 3, 2025, a resident with moderate cognitive impairment was hit on the face by another resident with severe cognitive impairment and schizoaffective disorder. Despite the incident being witnessed by a CNA and a physical therapist, and the CNA taking immediate action to separate the residents and notify a nurse, there was no documentation or investigation initiated. The CNA assumed that the administration had been notified, and the LVN who assessed the residents did not document the incident or notify the responsible party, believing that the Director of Nursing (DON) was involved. The Director of Rehabilitation (DOR) was informed by a physical therapist about the incident and directed the staff to the Administrator, who was in a meeting at the time. However, the Administrator misunderstood the nature of the issue and did not realize it involved resident aggression. Consequently, no investigation was conducted, and the facility's policy on abuse and neglect, which requires timely and thorough investigations, was not followed. This oversight placed residents at risk of further abuse and harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident #5, a female with hemiplegia and moderate cognitive impairment, required a mechanical lift for transfers, which was not accurately reflected in her care plan. The care plan incorrectly stated that she required total assistance from one staff member, contrary to the facility's policy that mandates the use of two staff members for mechanical lift transfers. Resident #7, a male with severe cognitive impairment and a history of aggressive behavior, did not have his aggressive tendencies addressed in his care plan. Despite documentation of aggressive incidents, including grabbing and spitting on staff, his care plan only included dietary needs. Interviews with staff revealed that they were aware of his aggressive behavior but lacked guidance from the care plan on how to manage it. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes, which were not met in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a secure environment for residents on one of its secure units by not having a functioning alarm on an exit door. This deficiency was identified during an observation and interview process, where it was revealed that the exit door on the secure unit did not have an alarm to alert staff if a resident exited. The secure unit housed seven residents, all of whom had a history of unauthorized departures or attempts, necessitating a secure environment for their safety. Despite the presence of staff on the unit, the lack of a functioning alarm posed a risk, as residents could potentially exit the building without staff knowledge, especially when staff were occupied with other duties. The issue was compounded by the fact that the facility's Maintenance Technician was aware of the problem since 2/3/25, when it was discovered that the wires for the door alarm had been pulled, rendering it nonfunctional. Although a temporary alarm was installed on 2/6/25, it was also found to be nonfunctional. The Administrator confirmed the absence of a functioning alarm and stated that a new alarm had been ordered. However, it was not until 2/10/25 that a new temporary alarm was installed, which successfully emitted a loud sound when the door was opened, indicating that the deficiency had persisted for several days without resolution.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's request to be assisted out of bed between 8:30 and 9:00 AM, which was a part of her daily routine and preference for attending the morning smoke break. The resident, who had a history of depression and required a mechanical lift for transfers, expressed that being out of bed and socializing during smoke breaks was important for her mental well-being. Despite her requests, the staff did not assist her out of bed at the requested time, leaving her in bed until later in the morning. The resident's medical records did not indicate any restrictions on her being out of bed or smoking, and there was no documentation of any limitations discussed with her. Interviews with staff revealed that the resident required two staff members for assistance, and it was sometimes deemed easier to assist her later in the day. However, staff acknowledged that there was time to assist her at her requested time, and no specific restrictions were communicated regarding her mobility or smoking. The Director of Nurses and other staff members had differing views on whether assisting the resident out of bed for smoking was a right or a privilege. The facility's policy on resident rights emphasized the importance of assisting residents in exercising their rights, but the resident was not informed of the facility's smoking policy or any related restrictions upon admission. The lack of signed admission documents and clear communication contributed to the deficiency in respecting the resident's rights and preferences.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The care plan did not address the resident's activities of daily living (ADLs), behaviors, and diagnosis of mental illness, which included schizophrenia and bipolar disorder. This oversight was identified during a review of the resident's records and interviews with facility staff. The resident, a female with a history of hemiplegia, depression, schizophrenia, bipolar disorder, and tobacco use, was admitted to the facility with significant physical and cognitive impairments. The Minimum Data Set (MDS) Admission Assessment indicated that the resident required maximal assistance with various ADLs and had moderately impaired cognition. Despite these needs, the comprehensive care plan did not include necessary details about the resident's ADLs, behaviors, or psychiatric diagnoses. Interviews with the Director of Nurses and other staff members revealed that the lack of documentation in the care plan made it difficult for staff to know the specific care required for the resident. The Director of Nurses acknowledged that the care plan should have included all relevant information from the MDS and that the absence of this information could lead to a decline in the resident's quality of life or care. The resident herself expressed dissatisfaction with the care provided, indicating that staff were not adequately trained to meet her needs.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and assistance devices to prevent accidents, specifically in the case of a resident who eloped from the facility. The resident, who had a history of dementia, vertigo, and anxiety disorder, left the facility without staff knowledge and was found at a convenience store 0.4 miles away. Despite having a care plan that included interventions for wandering, the resident was able to leave the facility unnoticed, indicating a lack of effective monitoring and supervision. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's elopement risk. The Director of Nursing (DON) and other staff members did not consider the incident an elopement, and there was no investigation conducted. The facility's policy on elopement was not followed, and the staff was unaware of the resident's departure until informed by another resident. The facility's exit doors were found to have alarms that were barely audible, and the staff could not see or hear the doors from the nurse's station. Additionally, the facility failed to maintain a safe environment in the shower room, where two spray bottles containing potentially harmful chemicals were left unsecured. These chemicals were not part of the facility's standard supplies, and their presence posed a risk of accidental ingestion or contact. The facility's Material Safety Data Sheets did not include information on these chemicals, further indicating a lapse in safety protocols.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with the mandatory electronic submission of staffing information to CMS based on payroll data in a uniform format. Specifically, the facility did not submit the required direct care staffing information for the first quarter of fiscal year 2024, which spans from October 1 to December 31. This failure was identified during a review of the CMS PBJ Staffing Data Report, which indicated that no data was submitted for the quarter, triggering a metric failure. The facility's policy mandates that staffing information be reported electronically to CMS through the Payroll-Based Journal system no less frequently than quarterly, with specific submission deadlines for each fiscal quarter. During an interview, the facility's Administrator stated that the corporate office was responsible for reporting the CMS PBJ staffing data. She explained that the previous company was responsible for reporting the first quarter staffing information, but it was not completed. The new corporate office did report the second quarter data. The failure to submit the first quarter staffing information could potentially place residents at risk for unmet personal needs, decreased quality of care, and a decline in health status and well-being.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents and areas within the facility. Observations revealed that Resident #27's bathroom soap dispenser was not attached to the wall, and Resident #5's bed remote control was held together with electrical tape, exposing wires. Resident #13's window blinds were broken and missing slats, while Resident #1's window blinds and windowsill were not securely attached, and the baseboard was detached. Resident #19's windowsill was also falling off, allowing outside air into the room, which concerned the resident due to potential mold exposure. The facility grounds were not maintained, with high grass, weeds, and debris observed around the premises. The shower room linen cart was dirty, and the baseboard was detached, with crumbled sheetrock present. Additionally, a hole in the concrete floor outside the dining room posed a potential fall risk. The maintenance staff was inexperienced, and the facility's maintenance equipment was not fully operational, contributing to the lack of upkeep. Interviews with staff revealed a lack of awareness and communication regarding maintenance issues. The Care Team Assignment Sheet, which was supposed to ensure room checks, was outdated, with rooms assigned to staff no longer employed. The facility's policy on providing a homelike environment was not effectively implemented, as evidenced by the numerous deficiencies observed during the survey.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate respiratory care for four residents, as observed during a survey. Resident #80's CPAP mask was found uncovered and not stored in a dated plastic bag on two separate occasions. This was contrary to the care plan and physician's orders, which required the CPAP mask to be applied at bedtime and stored properly when not in use. The lack of proper storage could lead to contamination and potential respiratory infections. Resident #22's nebulizer mask was also found uncovered and not stored in a dated plastic bag. This resident had a diagnosis of Chronic Obstructive Pulmonary Disease and required regular nebulizer treatments as per physician orders. The failure to properly store the nebulizer mask could expose the resident to harmful bacteria and increase the risk of respiratory infections. Similarly, Resident #19's oxygen tubing was not dated, and her nasal cannula was found uncovered. Resident #24's nebulizer mask was also found uncovered and not stored correctly. Interviews with staff, including an LVN and the DON, revealed a lack of training and adherence to the facility's policy on respiratory equipment storage. The facility's policy required respiratory equipment to be stored in a plastic bag with the date and resident's name to prevent infection, but this was not consistently followed.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the removal and destruction of expired drugs and biologicals in the medication storage room, as observed on May 28, 2024. During the inspection, seven bottles of expired medications, including Aspirin, Docusate Sodium, and natural tear eye drops, along with expired Skincote protective dressing applicators, were found. Interviews with staff revealed that the responsibility for removing expired medications was not clearly assigned, leading to the oversight. The Director of Nursing (DON) acknowledged that the staffing coordinator, who was responsible for this task, had left the facility a month prior, and the expired medications had not been addressed since then. Additionally, the facility failed to maintain a contamination-free environment in the medication room refrigerator. The refrigerator contained both resident nutritional supplements and staff personal food items, such as yogurt, drinks, and cheese sticks, which posed a risk of cross-contamination. Staff interviews confirmed that the refrigerator was used for personal food due to the lack of a staff refrigerator in the break room. The DON and other staff members recognized the potential for cross-contamination and the ineffectiveness of expired medications, but the issue persisted due to unclear responsibilities and the absence of a dedicated staff refrigerator.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program, resulting in the presence of pests in both the dining room and shower room. On May 28, 2024, during a resident meal service, flies were observed in the dining room, with one resident swatting a fly off her food and another having a fly land on her drink cup multiple times. The following day, on May 29, 2024, a small brown roach and a water bug were observed in the shower room, indicating a pest infestation. Interviews with facility staff revealed that the pest control was managed internally by the Administrator (ADM) and Maintenance Staff (MS) using over-the-counter products, as the commercial pest control company had stopped servicing the facility. The ADM was unaware of the reason for the discontinuation of the commercial service. Staff interviews indicated a widespread issue with flies, particularly in the dining room, and the presence of water bugs, especially during the summer. The facility's policy on pest control emphasized the need for frequent treatment and monitoring, but the current practices were insufficient to maintain a pest-free environment.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an incident of elopement involving a resident to the state survey agency. The resident, who has a history of dementia, vertigo, anxiety disorder, and lack of coordination, left the facility without staff knowledge and was found at a convenience store 0.4 miles away. Despite the resident's cognitive impairments and previous assessments indicating a risk of wandering, the facility did not recognize or report the incident as an elopement. The resident's care plan included interventions to prevent wandering, such as disguising exits and offering distractions, but these measures were not effective in preventing the resident from leaving the facility. On the day prior to the incident, the resident expressed a desire to walk to the store, which was denied by the charge nurse due to previous violations of the smoking policy. However, the following day, the resident managed to leave the facility unnoticed and was later retrieved by a CNA. Interviews with the facility's Administrator and DON revealed a lack of understanding and acknowledgment of the incident as an elopement. Both staff members did not report the incident to the state, believing it was a behavioral issue rather than an elopement. The facility's policy on abuse and neglect requires immediate reporting of such incidents, but this protocol was not followed, indicating a deficiency in the facility's response to potential neglect situations.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident had proper physician's orders and that these orders were followed for immediate care upon admission. Specifically, the facility did not provide physician's orders for fingerstick blood sugar checks for a resident with Type 2 Diabetes and Morbid Obesity. Additionally, the facility did not consistently check the resident's blood pressure as per the physician's orders. This oversight was identified during a review of the resident's records and interviews with facility staff, including the resident's physician and nurses involved in the resident's care. The resident, a female with a history of Type 2 Diabetes and Morbid Obesity, was admitted to the facility with specific medication orders, including insulin and blood pressure medication. However, the facility did not document consistent blood sugar and blood pressure monitoring, which are critical for managing her conditions. Interviews with the facility's staff revealed a lack of clarity regarding who was responsible for writing and confirming the orders, and there was a noted gap in the training of nurses on the facility's electronic health care charting system. The Director of Nursing acknowledged the importance of regular monitoring for residents with such diagnoses, but the facility failed to implement these standard care practices effectively.

Penalty

Fine: $8,172

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with Type 2 Diabetes and Morbid Obesity. The resident was admitted to the facility with a discharge medication list that included Insulin Glargine for diabetes and Lisinopril for high blood pressure. However, the baseline care plan was not completed until four days after admission and did not include instructions to address the resident's diabetes or physician orders. This oversight could place residents at risk of receiving inadequate care and services. Interviews revealed that the facility's nurses, including LVN A, had not been trained to create baseline care plans. The Director of Nursing (DON) admitted that she usually started the task of completing care plans, which are essential for guiding staff in providing care. The facility's admission checklist indicated that baseline care plans should be completed within the first 24 hours, but this was not adhered to in this case. The facility did not provide a care plan policy review before the exit.