Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Kennedy Health & Rehab during CMS and state inspections, most recent first.
A resident with a history of elopement and multiple diagnoses exited the facility unsupervised due to a malfunctioning secured unit door and alarm. Despite being identified as high risk and having interventions in place, staff did not consistently check or maintain the door's security, and several staff members were unaware of the door's status at the time of the incident. Surveyors observed the secured unit doors unlocked and unmonitored, confirming lapses in supervision and security.
A resident with a history of aggressive behavior physically assaulted two other residents on multiple occasions, despite care plans and interventions intended to prevent such incidents. The victims, both with severe cognitive impairments, were unable to advocate for themselves, and staff were aware of the ongoing risk but did not prevent further abuse. Facility policies on abuse were in place, but the measures taken were not effective in ensuring resident safety.
Surveyors observed that the facility failed to maintain a safe and sanitary environment, with a leaking ceiling at the south lobby entrance and multiple dining room chairs in the secured unit found to have rips, tears, and exposed cushions. Staff interviews confirmed these issues were ongoing, with temporary measures such as towels, buckets, and repeated roof sealing used to manage the leaks, and damaged chairs remaining in use for an extended period.
Multiple residents with cognitive and behavioral health conditions were involved in physical altercations, resulting in injuries such as fractures and scratches. Staff and administration failed to consistently report and investigate these incidents in a timely manner, and some residents lacked appropriate care planning and assessment. These failures led to Immediate Jeopardy being identified.
The facility did not develop or implement effective abuse prevention and reporting policies, resulting in multiple incidents of resident-to-resident abuse not being reported within the required timeframe, incomplete documentation, and lack of proper investigation. Several residents with cognitive and behavioral health conditions experienced physical harm, and staff and administration demonstrated a lack of understanding of reporting requirements and procedures.
Multiple incidents of resident-to-resident abuse, including physical altercations resulting in injuries such as a nose fracture and a vertebral compression fracture, were not properly investigated or reported by facility staff. Required documentation, such as written statements and state investigation reports, was not completed, and staff demonstrated a lack of knowledge regarding abuse reporting procedures. Several residents involved had cognitive or psychiatric conditions, and the facility failed to follow its own policies for abuse investigation and prevention.
Ceiling leaks and disrepair were observed in a resident hallway and two lobby entrances, with staff using towels and buckets to manage ongoing water intrusion. Maintenance efforts to seal the roof were unsuccessful, and exposed insulation and missing sheet rock were noted in one entrance area. The facility did not maintain a safe, sanitary, and comfortable environment as required by policy.
A resident admitted with bipolar disorder and epilepsy and later discharged to a psychiatric hospital did not have required entry and discharge MDS assessments completed or transmitted. The MDS nurse, who had limited training and started after the resident's stay, was unaware of the missing assessments until notified by the Administrator. Both the DON and Administrator confirmed that the MDS coordinator was responsible for these tasks, which were not performed as required by facility policy.
A resident with bipolar disorder and epilepsy was admitted without a baseline care plan completed within 48 hours, as required by facility policy. Staff interviews revealed confusion and lack of knowledge about who was responsible for developing the baseline care plan, and admission checklists did not consistently include this requirement. No baseline care plan, comprehensive care plan, or MDS assessment was documented for the resident.
A resident with severe cognitive and physical disabilities became combative, prompting intervention by two CNAs and an LVN. During the incident, the LVN was witnessed by both CNAs to have grabbed the resident by the shirt near the neck after the resident used a racial slur, causing the resident to cry and make a choking noise. The LVN denied intentional harm, but both CNAs confirmed the physical contact and the resident's distress. The facility's policies prohibit abuse, and the administrator stated staff are expected not to react physically to residents' provocations. The LVN was terminated following the incident.
A resident with severe cognitive and physical disabilities was allegedly grabbed by an LVN in a manner witnessed by two CNAs, resulting in distress to the resident. The CNAs did not immediately report the incident to the abuse coordinator or authorities, instead sending a text to the DON, who did not see it until the next morning. The incident was not reported to the state agency within the required two-hour window, and staff interviews revealed confusion about reporting procedures and the identity of the abuse coordinator.
A resident with severe cognitive and physical disabilities was allegedly physically abused by an LVN, who was suspended pending investigation. Despite the suspension, the LVN returned to the facility the same night, as staff were not informed of the suspension and allowed access to the premises. The facility's lack of a process to notify staff of suspensions led to a situation where residents and staff were placed at risk.
Kitchen staff did not effectively wear hair nets, and multiple food items in the refrigerator and freezer were found unlabeled, undated, unsealed, or expired. Freezers lacked thermometers, contained spills, and had improperly thawed foods. Beverage dispensers in the dining room were also not labeled or dated. Staff interviews confirmed lapses in food labeling, storage, and cleaning practices, and record reviews showed noncompliance with facility policies and federal food safety codes.
Staff failed to follow infection control protocols, including hand hygiene between meal tray distribution and use of PPE during care of a resident requiring enhanced barrier precautions for an indwelling catheter and G-tube. Facility policies for hand hygiene and EBP signage were not followed, and staff were unaware of the resident's EBP status.
A secured unit was found with soiled floors and walls, chipped paint, holes in sheetrock, and a buildup of black residue in common areas and multiple resident rooms. Several rooms had dirty floors, uncovered electrical outlets, broken faucets, broken paper towel dispensers, and broken light covers. Staff interviews revealed unclear cleaning responsibilities and a lack of maintenance follow-through, with the absence of a floor technician contributing to the deficiencies.
The facility did not maintain adequate lighting in the main dining room, with three of eight fluorescent lights not working and resulting in a consistently dim environment. Two cognitively intact residents, both dependent on staff for transfers and at risk for falls, reported the dining room was always dim. Multiple staff members either did not notice or did not report the lighting issue, and the Maintenance Director was unaware of the problem. The facility's policy required comfortable and adequate lighting, but this was not provided in the main dining area.
A resident with severe cognitive impairment and a history of brain hemorrhage was admitted to hospice care, but the facility did not complete a significant change MDS assessment within the required 14-day period. Documentation confirmed the hospice admission and care plan update, but staff interviews revealed a lack of awareness regarding the assessment requirement, and the responsible MDS nurse was unavailable.
Two residents who were totally dependent on staff for transfers were found using mechanical lift slings that were visibly damaged, including torn straps, frayed loops, loose stitching, and missing or illegible care tags. Staff confirmed the use of these slings despite facility policy and manufacturer guidelines requiring removal of worn equipment, resulting in an environment with accident hazards.
A resident's personal refrigerator was found with thick ice buildup, red-tinged ice, and an unidentifiable food container, indicating it had not been properly cleaned or defrosted as required by facility policy. The resident, who was cognitively intact and needed assistance with eating, confirmed the refrigerator was unclean. Staff interviews revealed that housekeeping was responsible for maintaining refrigerator cleanliness, but this duty was not fulfilled in this case.
The facility did not maintain the only kitchen refrigerator in safe working order, as the door latch was broken and the door would not close or seal properly. Staff interviews confirmed awareness of the issue, and the Dietary Supervisor noted it had been reported previously but not repaired. The facility's policy requires monthly inspections and immediate repairs, but the refrigerator remained unfixed until identified during survey.
A resident with a history of falls and independent toileting was found to have an inaccessible bathroom call light pull string, as it was wrapped up and could not be reached from the floor. Facility staff, including maintenance and the DON, confirmed the call light was not in compliance with policy, which requires call lights to be within reach for all residents.
The governing body did not appoint a state-licensed Administrator to manage the facility after the previous Administrator's departure. During this time, the MDS nurse, who had recently obtained her administrator license, had not officially accepted the position and was not present daily, leaving the DON to oversee operations.
Two residents were subjected to verbal abuse by staff, including a CNA making derogatory comments about a resident's hygiene and a cook engaging in a profane altercation with another resident. Both incidents were witnessed and documented, with the affected residents having no cognitive impairment and relevant medical conditions. The facility's policies prohibiting abuse were not followed, resulting in residents being exposed to inappropriate staff behavior.
The facility's governing body failed to appoint a state-licensed Administrator from December 2024 to February 2025, potentially affecting resident safety. The DON confirmed the absence of a full-time Administrator, and an interim Administrator was hired but inconsistently present. Staff interviews corroborated the lack of an Administrator, and the interim Administrator acknowledged the risk of non-compliance. Facility policy requires a licensed Administrator, which was not followed.
The facility failed to provide necessary personal hygiene services for two residents, leading to deficiencies in their care. One resident with dementia and paraplegia did not receive scheduled baths or nail care, resulting in long, dirty fingernails and dry skin. Another resident with anxiety and hypertension did not receive scheduled baths or facial hair removal, leading to visible hair on her chin. Staff interviews revealed issues with documentation and communication, indicating a need for improved oversight.
A hospice aide and two CNAs at an LTC facility failed to follow infection control protocols. The hospice aide did not wear a gown while providing care to a resident on enhanced barrier precautions, and the CNAs did not perform proper hand hygiene or change gloves during incontinent care. These actions were contrary to the facility's infection control policies.
Two residents with cognitive impairments eloped from a secured unit due to inadequate supervision and security measures. One resident climbed out of a window, while another exited through an unlocked door. Staff interviews revealed inconsistencies in monitoring security features, and observations noted missing safety locks and inaudible alarms.
The facility failed to ensure a working call system in Hall 400, compromising residents' ability to receive timely assistance. The call lights were not visible or audible to staff, and monitoring was inconsistent, posing a risk to residents. Despite this, residents reported not experiencing long waits for assistance.
The facility failed to maintain a safe and sanitary environment, with issues such as water-damaged ceilings, broken doors, unsecured cleaning agents, and accessible sterile supplies. Staff interviews revealed awareness of these problems but highlighted challenges in addressing them promptly. The lack of locks on supply rooms posed risks of contamination and tampering, contrary to the facility's policy of ensuring a safe and homelike environment.
Two residents in a secured unit were affected by a detached baseboard in their room, which remained unrepaired for several days. Both residents had severe cognitive impairments and required assistance with transfers, using wheelchairs. Despite being aware of the issue, the Maintenance Supervisor did not prioritize the repair, and the facility's policy to provide a safe and comfortable environment was not upheld.
A resident with major depressive disorder had medications discontinued, but the MAR was not updated to reflect this change. Nursing staff failed to document the resident's hospitalization and continued to initial the MAR as if medications were administered. The DON confirmed that proper charting training was provided, but accurate documentation was not maintained.
A resident with a tracheostomy did not receive proper respiratory care due to inadequate training and competency checks for staff. Observations showed that an LVN reused a single-use suction catheter, did not use sterile technique, and used tap water during suctioning. Interviews revealed that staff lacked proper training, and the DON admitted to disruptions in the training process. The facility's policy required sterile technique, but these standards were not met, placing the resident at risk.
The facility failed to ensure nursing staff had the necessary competencies and skill sets, resulting in improper care and lack of PPE use during resident care. CNAs did not clean a resident properly or use PPE, while LVNs failed to use sterile techniques and PPE during wound and trach care. Staff reported inadequate training and competency evaluations, contributing to these deficiencies.
The facility failed to maintain an effective pest control program, resulting in gnats in hallways, a nurse's station, and resident rooms. Observations showed gnats around a resident's tracheostomy and in another resident's room due to trash accumulation. Staff and family reported ongoing issues, with inconsistent pest control measures. The facility's pest control policy was not followed, leading to unsanitary conditions.
A long-term care facility failed to maintain an effective infection control program, as staff did not adhere to proper PPE use and sterile techniques. Two CNAs did not wear appropriate PPE or sanitize hands during care, an LVN did not use a gown for wound care, and another LVN failed to maintain sterile technique during trach care. Staff were unaware of enhanced barrier precautions and lacked adequate training.
Two residents in the facility were observed without privacy covers on their urinary drainage bags, compromising their dignity. One resident, with quadriplegia, was seen in the dining room with an exposed drainage bag, despite his care plan requiring a privacy cover. Another resident, with epilepsy, had her drainage bag visible from her room, and she was not informed about the need for a privacy cover. The facility's policies and staff expectations were not followed, leading to this deficiency.
Two residents in a long-term care facility did not receive scheduled personal hygiene care, including bathing and grooming, due to staff shortages and scheduling issues. One resident, with quadriplegia and diabetes, had long, dirty fingernails and dry skin, while another resident, also with quadriplegia, had unkempt nails and facial hair. Despite being aware of the issues, the facility's administration failed to ensure adherence to the scheduled care, impacting the residents' dignity and potentially their health.
Two residents in the facility experienced inadequate pressure ulcer care and monitoring. One resident, with diabetes and quadriplegia, did not receive consistent weekly skin assessments, and reported infrequent wound care. Another resident, with a hip fracture and Alzheimer's, had a skin condition on her heel that was not identified by staff until a sitter reported it. Interviews with staff revealed systemic issues with completing and documenting weekly skin assessments, despite facility policies requiring them.
The facility failed to provide proper incontinent and catheter care for two residents. A resident with severe cognitive impairment did not receive adequate perineal care, as observed when a CNA failed to clean the penis properly. Another resident with an indwelling catheter had her urinary drainage bag tubing lying on the floor without a securement device. The facility's policies require proper cleaning and securing of catheter tubing to prevent infections.
The facility did not update its comprehensive facility-wide assessment for over a year, with the last update in February 2023. The Administrator, who started in July 2024, acknowledged the oversight, noting that only the first page was updated to reflect a new Medical Director. The facility's policy requires an annual review, which was not adhered to.
The facility failed to ensure residents were orally informed of their rights. Eight residents reported that the Activity Director had not reviewed or explained their rights, and record reviews confirmed that resident rights had not been reviewed over the past five months. The Administrator acknowledged that the list of rights had not been reviewed with the residents during their stay.
The facility failed to follow the menu and ensure proper portion sizes for two lunch meals, resulting in residents not receiving the appropriate types and amounts of food. Incorrect utensils were used, leading to improper portion sizes, and substitutions were made without following recipes or proper measurements. The dietary manager and kitchen staff did not coordinate effectively, and a resident who was supposed to receive large portions did not get them due to a lack of food.
The facility failed to maintain sanitary conditions in the kitchen, with staff observed engaging in unsanitary practices such as touching food and plates with bare hands, not wearing aprons, and returning spilled food to serving containers. The dietary manager did not monitor the food service line, leading to potential risks of foodborne illness for residents.
The facility failed to ensure accurate PASRR Screenings for two residents with mental health disorders. Both residents were admitted with diagnoses requiring antidepressant and antipsychotic medications, but their PASRR Level 1 Screenings inaccurately indicated no evidence of mental illness. The MDS Nurse admitted the inaccuracies were not addressed due to training a new MDS Nurse.
The facility failed to post accurate daily nurse staffing information for the 6 AM-2 PM shift on three consecutive days. The posted reports inaccurately included the DON, ADON, and MDS Nurse in the count of nurses providing direct resident care, despite these individuals not performing direct care duties for the full duration of their shifts. This misrepresentation was confirmed through interviews and a review of the nursing schedules.
Failure to Maintain Secured Unit Doors and Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that the resident environment remained as free from accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for one resident identified as an elopement risk. The secured unit's 800 hall door alarm and lock were not functioning properly, which allowed a resident with a history of elopement and multiple diagnoses, including vascular dementia, schizophrenia, and cerebral palsy, to exit the facility unsupervised. The resident was found outside in the parking lot by staff, and it was noted that the alarm on the door was not heard by staff at the time of the incident. Record reviews indicated that the resident had previously been identified as a high elopement risk, with documented incidents of leaving the facility and a care plan in place that included interventions such as 1:1 monitoring and frequent checks. Despite these interventions, staff interviews revealed inconsistent practices regarding door checks and alarm functionality. Several staff members, including CNAs and nurses, reported that they did not know why the secured unit door was unlocked or why the alarm was not functioning at the time of the incident. Maintenance and nursing staff also reported finding the door unlocked and the alarm not working on other occasions, raising concerns about the reliability of the security measures in place. Observations by surveyors further confirmed that the secured unit doors were found unlocked and unmonitored during their visit, with no staff present in the area and multiple residents standing near the unsecured doors. Staff interviews indicated a lack of awareness and communication regarding the status of the doors and alarms, as well as uncertainty about procedures when maintenance was being performed. Documentation logs indicated that the doors and alarms were supposed to be checked daily, but these checks did not prevent the deficiency from occurring.
Removal Plan
- Resident was returned to unit by CNA and assessed for injury by nurse working shift.
- Resident was placed on monitoring every 15 minutes until risk resolved.
- Maintenance supervisor checked all doors on the secured unit for alarms and proper functioning.
- The nurse completed head count to ensure all residents were safe on the unit.
- In-services started with secured unit staff and other departments to ensure unit remains secure, and residents remain safe.
- Administrator or designee will in service all employees that work or will work on secured unit prior to starting their shift so they are made aware of changes.
- Inservice consists of nursing making walking rounds to check the alarms doors for proper functioning at the beginning and end of each shift.
- Secured unit staff is to always have 2 staff members.
- CNA must report to nurse when taking break and nurse must inform other nurse on duty when she is on break and inform CNA staff when nurse is taking break and who to contact in case any issues occur.
- Administrator in-serviced environmental supervisor - laundry staff should be making rounds on secured unit and collecting soiled linen. This allows secured unit staff to remain on secured unit to provide supervision and care to residents.
- Laundry Staff were in serviced by environmental supervisor.
- In-services completed by Administrator with maintenance supervisor that she must remain on secured unit any time that maintenance is being done on secured unit and inform staff when maintenance is being done.
- Check the doors to make sure they remain locked.
- Administrator started in services with secured unit staff so they are aware the secured unit must always have 2 employees on the secured unit for resident safety.
- CNAs must report to nurse when taking a break to ensure appropriate staffing is on the secured unit.
- Nurses must inform other nurses on shift when they are taking their break and make sure the CNAs are aware, so they know who to contact if there are any issues while nurse is on break.
- In-services will be completed with staff prior to working shift on secured unit.
- Administrator started in services with secured unit nurses to ensure they are doing walking rounds at the beginning and the end of each shift to check the functioning of alarms and doors.
- Completing a head count at the beginning and end of each shift and report any issues found immediately.
- In-services will be completed prior to working shift on secured unit.
- Administrator and other department managers started Inservice on elopement.
- Facility must follow policy and procedure regarding elopement.
- Establish a monitoring system until risk has resolved and assign staff to sit one on one with resident until risk resolved.
- All nurses will be in serviced over changes to elopement policy and monitoring system prior to working shift.
- Elopement policy and procedure were revised to state a staff will sit one on one with resident until the risk of elopement has resolved.
- One on one form has been created, and staff must follow guidelines on monitoring form.
- Guidelines include staff must always remain within arm's reach, resident must remain in line of sight continuously, document observations every 15 minutes, report any changes in behavior to charge nurse.
- Administrator started in services with all staff and make sure staff is in serviced prior to starting shift.
Failure to Protect Residents from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse by another resident, resulting in repeated incidents of physical aggression. Specifically, one resident with a history of aggressive behaviors and multiple psychiatric and neurological diagnoses physically assaulted two other residents on three separate occasions. The incidents included hitting another resident on the shoulder and legs while verbally cursing, and striking a third resident on the thigh with his fists. These events were witnessed and documented by staff, and the aggressive resident's care plan had previously identified a risk for such behaviors, with interventions such as redirection and monitoring in place. The residents who were victims of the abuse had significant cognitive impairments and were unable to answer questions appropriately during interviews. Their care plans included interventions for monitoring and removing them from situations involving aggressive behavior, but these measures did not prevent the repeated incidents. Staff interviews confirmed that the aggressive resident was known for such behaviors, and attempts to transfer him to a behavioral hospital were unsuccessful due to his health status and guardian refusal. Documentation showed that staff were aware of the aggressive resident's behaviors and had updated care plans following incidents, but the interventions implemented were insufficient to prevent further abuse. The facility's policies on abuse and resident-to-resident aggression were in place, but the repeated nature of the incidents indicated a failure to ensure the safety and protection of residents from abuse and neglect as required.
Environmental Deficiencies: Leaking Ceiling and Damaged Dining Room Chairs
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two key areas: the south lobby entrance and the dining room chairs in the secured unit. Multiple observations over several days revealed that the ceiling at the south lobby entrance was leaking water, with towels and buckets placed underneath to catch the water. At one point, a section of pink insulation was observed hanging from the ceiling, which was later removed and the hole repaired, but the area continued to leak. Staff interviews confirmed that the roof had been an ongoing problem, leaking whenever it rained, and that temporary measures such as sealing the roof and placing towels and buckets were routinely used. Staff also noted that the leaking ceiling could cause falls, changes in resident condition, and affect health and dignity. Additionally, the dining room chairs in the secured unit (hall 900) were found to be in poor condition, with 14 chairs observed to have rips, tears, and holes, and 6 chairs with exposed inner cushions. Residents were seen sitting in these damaged chairs during observations. Staff interviews indicated that the chairs had been in poor condition for a long period, with the materials peeling and becoming worn quickly, and that the exposed cloth and foam could present cleaning and disinfecting challenges. The facility's policy requires a safe, clean, and comfortable environment, but these conditions were not met in the areas observed.
Failure to Protect Residents from Abuse and Timely Reporting of Incidents
Penalty
Summary
The facility failed to ensure residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by multiple incidents involving resident-to-resident altercations. Several residents with cognitive impairments and behavioral health diagnoses were involved in physical altercations, resulting in injuries such as a non-displaced nose fracture and a lumbar vertebral fracture. Documentation revealed that one resident was hit in the back by another, another was punched in the face, and another was pushed to the ground, all occurring within a short time frame. Additionally, a resident was grabbed, pulled, and scratched by another resident, leaving visible marks. The facility's records and staff interviews indicated that there were lapses in timely reporting and investigation of these incidents. The Administrator was unaware of the requirement to report abuse within two hours and did not report certain altercations to the state agency, believing that no injury had occurred. There was also a lack of comprehensive care planning for some residents, and staff did not consistently notify supervisory personnel of altercations as required. In some cases, the facility did not complete or document required assessments and care plans for residents involved in these incidents. Interviews with staff and review of documentation showed that staff responses to altercations varied, with some staff intervening and notifying supervisors, while others did not follow established protocols. The facility's failure to protect residents from abuse and neglect, as well as the lack of timely and appropriate reporting and investigation, led to the identification of Immediate Jeopardy. The deficiencies placed residents at risk for continued abuse and negative psychosocial outcomes.
Removal Plan
- Residents were separated from each other and monitored until no further aggressive behaviors were demonstrated.
- Resident #5, #2, and #1 were referred to behavioral unit for inpatient treatment.
- Resident #2 was sent to ER for evaluation and treatment.
- Prior to being admitted to inpatient behavior hospital, #2 & #1 were sent to ER for evaluation and treatment.
- Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect.
- All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements.
- In-services will continue; all staff must be in-serviced before starting their shift.
- Documentation of re-education and staff signatures will be completed; all staff will be in-serviced before starting their shift.
- Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately.
- Department heads started safety survey assessments and will have all safety survey assessments completed on all residents that could give a response at north nurse's station.
- Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition.
- Administrator will hold Resident council meeting to discuss abuse/neglect for residents that would like to attend.
- All residents that did not attend resident council will be talked to individually by department heads and family will be contacted for residents that have impaired cognition.
- Medical director notified of Immediate Jeopardy in facility.
Failure to Implement and Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for multiple residents reviewed for abuse policies. Specifically, the facility did not report incidents of resident-to-resident abuse within the required 2-hour timeframe, as outlined in their own policy. Several incidents were not reported to the state agency until days after they occurred, and in some cases, were not reported at all. Additionally, the facility did not gather required written statements for these incidents, nor did they complete the State Provider Investigation Report (5-day report) as mandated by their policy. The report details several incidents involving residents with significant cognitive impairments and behavioral health diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and psychotic disorders. In one instance, a resident was hit in the back by another resident, and in another, a resident was punched in the face, resulting in a non-displaced nose fracture. There were also incidents where residents were scratched, pushed, or otherwise physically harmed by other residents, leading to injuries such as skin tears and a vertebral compression fracture. Despite these events, the facility failed to follow its own procedures for documentation, investigation, and timely reporting. Interviews with staff and administration revealed a lack of understanding and adherence to the facility's abuse reporting policy. The Administrator was unaware of the 2-hour reporting requirement and did not know about the necessary forms and investigation timelines. Other staff members described notifying supervisors but did not consistently follow through with required documentation or reporting. The facility also failed to analyze these occurrences to determine if changes to policies and procedures were needed and did not refer all incidents to the QAPI committee for further review, as required by their own policy.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to inpatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.
- Abuse reportable events policy was reviewed and revised to include steps for reporting, documentation required and time to report events.
- Abuse/neglect in-services were started with all staff by the Administrator, the DON, nurse managers and department supervisors; all employees must be educated before working their scheduled shift.
- Social Services in-serviced Administrator to complete safety surveys with each incident, especially any allegations of abuse/neglect, to ensure residents feel safe in the facility and they have not experienced any negative events.
- The DON and Nurse manager assigned to educate nurses on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments.
- Per facility policy, charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON.
- Safety surveys started by department heads for residents that could answer survey questions; secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition.
- Resident council meeting scheduled for residents to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event.
- Department heads would speak to residents individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents.
- The Regional director of operations in-serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax.
- Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email.
- The Nurse manager started in-service with nurses to discuss documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. In-service was related to having more thorough assessment and appropriate documentation in place. In-services would be completed before staff worked the next shift.
- The facility's Abuse Reportable events Policy was reviewed and revised to clarify timelines for internal/external reporting and investigation steps. The revised policy was approved by the Governing Body and redistributed to all departments.
- Future new hires will receive abuse prevention and reporting training during orientation before working any shift.
- The DON or designee will initiate and complete all abuse investigations using the state-approved Form 3613-A process.
- All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.
- The Administrator or DON will audit all incident reports weekly to ensure proper reporting, investigation, and documentation.
- Results will be presented to the QA Committee monthly for review and any needed corrective actions.
- The QA Committee will evaluate compliance and determine if further education or policy revisions are needed.
Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that further potential harm was prevented while investigations were in progress. Multiple incidents involving resident-to-resident altercations were not properly investigated, and required documentation such as written statements and State Provider Investigation Reports were not completed as per facility policy. For example, one resident was hit in the back by another, another resident was grabbed and scratched, and a third incident involved a resident being pushed to the ground, resulting in injury. In another case, a resident was punched in the face, causing a non-displaced nose fracture. In each of these cases, the facility did not gather written statements or complete the required 5-day investigation reports. The report details that the facility did not analyze the circumstances of these incidents to determine if changes to policies or procedures were needed to prevent recurrence. There was also a lack of review and documentation of corrective actions for these incidents. The Administrator and other staff demonstrated a lack of knowledge regarding the required reporting timeframes and procedures for investigating and documenting abuse allegations. Interviews revealed that the Administrator was unaware of the 2-hour reporting requirement and the necessity of completing and submitting the 5-day investigation report to the state agency. Additionally, the facility's own policy on resident-to-resident abuse, which outlines steps for investigation and reporting, was not followed. Several residents involved in these incidents had significant cognitive impairments or psychiatric diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder. The incidents resulted in physical injuries, including a nose fracture and a vertebral compression fracture, as well as psychosocial harm. The facility's failure to follow its own policies and regulatory requirements for investigating and reporting abuse led to an Immediate Jeopardy situation, as residents were placed at risk for further harm, unrecognized abuse, and emotional distress.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behaviors were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to the ER, while in the ER staff made referral to inpatient behavioral hospital. Both Resident #2 & #1 were admitted to inpatient behavioral hospital.
- Care plans reviewed and updated as needed for incidents reported.
- Staff separated residents and monitored for any additional behaviors or until placement occurred for residents. When no additional behaviors occurred, residents were removed from monitoring.
- In house psychiatric services are contacted with behavioral incidents for evaluation and additional treatment if needed.
- All staff will be re-educated on the Abuse/Neglect Policy and the procedures for reporting, documenting, and investigating all allegations of abuse or neglect; in-services started by the Administrator, the DON, nurse manager, and department managers and will continue until all staff were in-serviced and no staff will work their scheduled shift until in-serviced.
- Inservices to discuss resident behaviors, how to de-escalate and prevention; all staff must be in-serviced before working their scheduled shift.
- Facility has asked contact from local behavioral hospital to conduct training with staff during mandatory Inservice.
- Inservices related to reporting allegations of abuse to Administrator and DON immediately. Re-education will continue; no staff is to work their scheduled shift until in-services are completed for them.
- RDO trained Administrator and DON on investigating, prevention, and report abuse/neglect allegations.
- RDO in-serviced Administrator/DON with this information.
- Staff in-services were started with staff over completing witness statements, abuse and neglect (timely reporting and types of abuse), safety surveys when state surveyors mentioned these issues.
- Revision of policy and procedure was loaded into staff communication system so everyone who has already signed in-services was made aware of revision to policy.
- Regional Director of operations visits the facility on monthly basis and will follow up with the Administrator/DON with each self-report to ensure investigation of self-reports are completed in timely manner and 3613 is submitted to state with all the documentation gathered with investigation. All communication between monthly visits is to be sent through email.
- In-services for documentation including witness statements and monitoring for required documentation that is needed with incidents, including witness statements and monitoring, all staff will be in-serviced prior to start of shift.
- Nurse manager started Inservice for all Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that is required for investigation. This information was also included in facility communication for all nurses.
- Department heads started safety survey rounds for residents.
- Charge nurse on secured unit contacting family members for residents that reside on the secured unit to complete safety survey for residents that have impaired cognition; facility is awaiting phone calls from 4 family members where facility left voicemail.
- Resident council scheduled with residents to discuss changes to policy and what is required when these types of allegations are reported.
- Department heads will speak to each resident that did not attend resident council meeting individually and for those that have impaired cognition family members will be contacted.
- The Administrator and DON will personally review all incident reports and abuse allegations within 2 hours of occurrence to ensure timely reporting, investigation, and documentation.
- The Social Services Director and Unit Managers will monitor daily for any new behavioral incidents and report immediately to administration.
- The DON or Designee will complete a daily audit of all incident logs for 30 days, then weekly for 90 days.
- Audit results will be documented and discussed in QA meeting for review and corrective follow-up.
- Any staff member who fails to report, investigate, or document an allegation of abuse appropriately will be subject to disciplinary action up to and including termination.
- The QA Committee will review all incident reports and abuse allegations monthly for 90 days to ensure that each incident is investigated, documented, and reported according to policy.
Ceiling Leaks and Disrepair in Resident Hallway and Lobby Entrances
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in specific areas, including one resident hallway (900 hall secured unit) and two main entrances (north and south lobby entrances). Observations over several days revealed ongoing water leaks from the ceilings in the 900 hall and the south lobby entrance, with towels and buckets placed underneath to catch the water. The north entrance lobby ceiling was found to have missing sheet rock, exposing the frame and insulation. These issues were consistently present during the survey period. Interviews with staff confirmed that the ceiling leaks occurred whenever it rained, and that the problem had persisted for an extended period. Staff routinely placed towels and buckets to manage the water, and housekeeping staff emptied the buckets and cleaned the affected areas daily. The maintenance supervisor reported repeated attempts to seal the roof, but these efforts did not resolve the leaks. The north entrance area was reported to be dry at the time of the survey, but the ceiling remained unrepaired. The facility's policy requires a safe, clean, and comfortable environment, but the ongoing leaks and ceiling disrepair were not corrected, resulting in an environment that was not in compliance with these standards.
Failure to Complete and Transmit Required MDS Assessments
Penalty
Summary
The facility failed to complete and transmit required Minimum Data Set (MDS) assessments for a resident who was admitted with diagnoses including bipolar disorder and epilepsy and later discharged to a psychiatric hospital. Record review showed that no MDS assessments, including entry and discharge MDS, were completed or transmitted for this resident, despite multiple assessments being due according to the facility's electronic medical record system. The MDS tracking tab indicated several assessments with Assessment Reference Dates (ARDs) that were not completed or submitted. Interviews revealed that the MDS nurse, who started after the resident's admission and discharge, had minimal training and was unaware of the outstanding MDS assessments until informed by the Administrator. The Director of Nursing (DON) and Administrator both acknowledged that the MDS coordinator was responsible for timely completion and transmission of MDS assessments, and that these had not been done as required for the resident in question. Facility policy requires all MDS assessments to be completed and transmitted in accordance with OBRA regulations, which was not followed in this instance.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Record review showed that the resident, a male with diagnoses including bipolar disorder and epilepsy, was admitted without a baseline care plan, comprehensive care plan, or MDS assessment documented in the electronic medical record. Interviews with staff revealed confusion and lack of knowledge regarding responsibility for completing baseline care plans, with the MDS Coordinator, floor nurses, ADON, and DON each providing differing accounts of who was responsible. Admission checklists used by floor nurses did not consistently include the baseline care plan requirement, and staff were unaware of the required timeframe for completion. The deficiency was further evidenced by staff interviews indicating that the process for developing baseline care plans was not clearly assigned or understood. The MDS Coordinator had no prior experience and was unaware of the 48-hour requirement, while the ADON and floor nurses were not informed of their roles in the process. The administrator and DON also provided inconsistent information about who was responsible for ensuring baseline care plans were completed. Facility policy clearly stated that a baseline plan of care must be developed within 48 hours of admission to meet residents' immediate needs, but this was not followed for the resident in question.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a facility failed to protect a resident from physical abuse by a staff member. The incident involved a male resident with severe intellectual disability, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficits, who had a BIMS score indicating severe cognitive impairment. On the evening in question, the resident became combative with his roommate and staff, requiring intervention from two CNAs and an LVN. During the attempt to assist the resident, the LVN was witnessed by both CNAs to have grabbed the resident by the shirt near his neck and made a choking noise, causing the resident to cry. The LVN's actions were in response to the resident using a racial slur, and both CNAs confirmed the physical contact and the resident's distress during interviews. The resident himself reported being choked and expressed fear of the LVN during an interview. The facility's documentation and staff interviews confirmed that the LVN entered the resident's room after being called for assistance due to the resident's combative behavior. The LVN admitted to having his hand caught in the resident's shirt near the neck but denied intentionally choking the resident. However, both CNAs present in the room described the LVN grabbing the resident by the shirt at the neck and getting into his face after the resident used a racial slur. The CNAs reported that the resident made a choking noise and cried after the LVN released him. The incident was also discussed in a voice recording provided by one of the CNAs, where both CNAs recounted the LVN's actions to him, and the LVN did not deny the events but stated he did not remember. The facility's policies prohibit any form of abuse or neglect, and the administrator stated that staff are expected to act professionally and not choke residents or react to verbal provocations. The LVN involved was terminated following the incident. The resident was assessed and found to have no physical injuries, but the incident was substantiated through multiple staff interviews, resident statements, and documentation. The failure to prevent and immediately address the physical abuse by the LVN constituted a deficiency in protecting residents from abuse.
Failure to Timely Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred in which a male resident with severe intellectual disability, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficit was allegedly grabbed by the shirt near his neck by an LVN during an altercation with his roommate. Two CNAs witnessed the event, with one reporting that the resident made a choking noise and cried after being released. Both CNAs considered the actions to be abuse. Despite witnessing the incident, the CNAs did not immediately report the alleged abuse to the abuse coordinator or other appropriate authorities. One CNA sent a text message to the DON late in the evening, but did not attempt to call or notify anyone else, and was unaware of who the abuse coordinator was. The DON did not see the text until the following morning and only then initiated the reporting and investigation process. The administrator and DON both confirmed that the incident was not reported to the state agency until the next morning, well beyond the required two-hour timeframe. Interviews revealed that staff were unclear about the reporting process, the identity of the abuse coordinator, and the urgency required in reporting suspected abuse. Record reviews and interviews confirmed that the facility's policies required immediate reporting of abuse, but staff failed to follow these protocols. The incident was not reported in a timely manner, and the required notifications to the administrator and state agency were delayed. The deficiency was identified as Immediate Jeopardy due to the failure to report the allegation of abuse within the mandated timeframe and the lack of staff knowledge regarding abuse reporting procedures.
Failure to Prevent Suspended LVN from Facility Access After Alleged Abuse
Penalty
Summary
The facility failed to prevent further potential abuse after an alleged incident of physical abuse involving a resident with severe intellectual disability, anxiety disorder, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficit. The resident, who had a BIMS score indicating severe cognitive impairment, was reportedly grabbed by the shirt and neck by an LVN, causing the resident to choke. This incident was witnessed by two CNAs, who later confirmed the details in a voice recording and interviews. The resident expressed fear and distress during an interview, stating that the LVN had choked him. Despite the LVN being suspended pending investigation on the morning following the incident, the LVN returned to the facility that same night to document an incident report. Staff on duty were unaware of the suspension and allowed the LVN access to the facility, including the computer and secured unit, although they did not observe direct interaction with residents. The CNAs stated that if they had known about the suspension, they would have reported the LVN's presence and not allowed access, recognizing the risk posed to residents and staff. The facility's policies required that suspended employees not be permitted on the premises or to engage with residents or staff during suspension. However, the administrator acknowledged that there was no process in place to inform staff of suspensions, relying instead on the suspended employee's understanding of the policy. This lack of communication allowed the suspended LVN to return to the facility, placing residents and staff at risk and resulting in the identification of an Immediate Jeopardy situation by surveyors.
Failure to Maintain Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. Observations revealed that kitchen staff, including the dietary manager, dietary aide, and cook, did not effectively wear hair nets, leaving hair exposed on the front, sides, and backs of their heads. Additionally, food items in the refrigerator and freezer were found to be unlabeled, undated, and in some cases unsealed. Specific items such as premade turkey sandwiches, salad mix, and bags of cheese slices were not properly labeled or sealed, and expired food was present in the refrigerator. Freezers lacked thermometers, contained half-thawed and unlabeled food items, and had visible spills that were not cleaned up. Beverage dispensers in the dining room were also not labeled or dated. Interviews with dietary staff and supervisors confirmed that food should be dated and labeled upon preparation, storage, or delivery, and that expired foods should be discarded promptly. Staff acknowledged that proper thawing procedures were not followed, as meats were found thawing in standing water rather than under running water or in the refrigerator. The dietary supervisor also reported that the refrigerator door had a broken seal that had not been repaired, which could compromise food safety. Staff admitted to not having received in-service training on kitchen duties since being hired and recognized the importance of cleaning spills immediately and maintaining proper food storage practices. Record reviews of facility policies and federal food safety codes indicated that the facility was not adhering to established guidelines for food labeling, storage, temperature monitoring, and sanitation. Policies required daily temperature checks, proper labeling and dating of all food items, and immediate cleaning of spills, none of which were consistently followed. The lack of compliance with these standards placed residents at risk of foodborne illness and food contamination, as directly stated in the report.
Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices involving both staff and a resident. Specifically, a certified nursing assistant (CNA) did not sanitize her hands between passing and setting up meal trays for residents, only sanitizing before starting the task and not between each resident. This was confirmed through observation and interview, where the CNA acknowledged not considering the need for hand hygiene between residents. Additionally, two CNAs performed foley and incontinent care for a resident with an indwelling catheter and G-tube without wearing the required personal protective equipment (PPE) and without enhanced barrier precaution (EBP) signage on the resident's door, as required by facility policy. The resident involved had severe cognitive impairment, was dependent on all activities of daily living, and required enhanced barrier precautions due to the presence of medical devices. Both CNAs involved in the care were unaware of the resident's EBP status and did not use appropriate PPE during high-contact care activities. Facility policies reviewed indicated clear requirements for hand hygiene before and after handling food and for the use of gloves and gowns during care of residents on EBP, including posting appropriate signage. These deficiencies were confirmed through staff interviews and record reviews.
Failure to Maintain Sanitary and Safe Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of its secured unit hallways. Observations revealed widespread environmental concerns, including soiled floors and walls, chipped paint, holes in the sheetrock, and a buildup of thick black residue in the common area, dining room, shower, and multiple resident rooms. Specific resident rooms were found with dirty floors, uncovered electrical outlets, broken faucets, broken paper towel dispensers, and broken light covers. Some rooms had a strong urine odor and sticky substances mixed with dirt and food particles on the floors. Interviews with housekeeping and maintenance staff indicated a lack of clarity and follow-through regarding cleaning responsibilities and maintenance repairs. The housekeeper reported daily cleaning tasks but noted that deep cleaning was the responsibility of maintenance, which was hindered by the absence of a floor technician. The maintenance director, new to the position, was unaware of the broken items and confirmed the lack of a floor technician. The housekeeping supervisor acknowledged the need for more thorough cleaning and committed to increased monitoring. The administrator cited recent management turnover and stated that corporate maintenance was overseeing the issues. Facility policy required a clean, sanitary, and orderly environment with daily and monthly deep cleaning, which was not being met in the secured unit.
Inadequate Lighting in Main Dining Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in the main dining room due to inadequate lighting. During observation, it was noted that three out of eight fluorescent lights were not working, resulting in a dim and dreary atmosphere. Two residents who were cognitively intact and dependent on staff for transfers reported that the dining room was consistently dim, with some lights never working properly. Staff interviews revealed that several staff members had not noticed the lighting issue or had not reported it, assuming maintenance would address it or that the lighting was normal for the building. The Maintenance Director was unaware of the problem, and the DON acknowledged the dimness but attributed it to the age of the facility. The Administrator confirmed awareness of some lights being out but stated that no issues had been reported to her prior to the survey. Record reviews indicated that the affected residents had significant medical conditions, including cervical spinal stenosis, muscle weakness, diabetes, heart failure, and unsteadiness on their feet, and were at risk for falls. The facility's policy required comfortable and adequate lighting in all areas to promote a safe and homelike environment, but this standard was not met in the main dining room, as evidenced by the observations and resident interviews.
Failure to Complete Timely Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a resident experienced a significant change in condition, specifically following the resident's admission to hospice care. Record review showed that the resident, an elderly male with a diagnosis of traumatic brain hemorrhage and severely impaired cognition, was admitted to hospice services, as documented in the care plan and physician's orders. However, there was no evidence that a significant change MDS assessment was completed within the required timeframe after the hospice admission. Interviews with facility staff revealed that the DON was unaware that a significant change MDS was required upon hospice admission and confirmed that the MDS nurse, who was responsible for these assessments, was unavailable at the time due to hospitalization. The facility's policy and CMS RAI guidelines both require a comprehensive assessment upon significant change in condition, including hospice enrollment, but this was not followed for the resident in question.
Failure to Remove Damaged Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service for two residents who were totally dependent on staff for transfers. One resident, a male with cervical spinal stenosis, muscle weakness, and diabetes, was observed sitting in a wheelchair on a mechanical lift sling with a torn main strap, frayed loops, loose stitching, and an illegible care tag. The resident reported that the lift was not always used for transfers, but it was used on the day of observation due to his feeling weak. Another male resident with cerebral infarction, cerebral palsy, and anxiety was also found with a mechanical lift sling that had frayed loops, a torn main strap, a hole in the mesh body, loose stitching, and no care tag. Staff interviews confirmed that the damaged slings were in use and that there were 11 residents in the facility who required mechanical lifts for transfers. The facility's policy and manufacturer guidelines both required that slings showing signs of wear, such as rips, tears, or fraying, be immediately removed from use. Despite these requirements, the slings remained in use, creating an environment with accident hazards for residents dependent on mechanical lifts.
Failure to Maintain Sanitary Conditions in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident's food items in accordance with its own policy. Observation of a personal refrigerator in a resident's room revealed thick ice buildup, red-tinged ice in the drip tray, and an unidentifiable plastic container with a green substance frozen into the ice. The refrigerator was not clean or defrosted, and the food items inside were unidentifiable. The resident, who was cognitively intact and required setup or clean-up assistance with eating, stated that he would not eat anything from the refrigerator and acknowledged it needed cleaning and defrosting. Interviews with facility staff, including the DON, housekeeping supervisor, and administrator, confirmed that housekeeping was responsible for cleaning and monitoring the cleanliness and temperature of personal refrigerators. The housekeeping supervisor indicated that refrigerators were supposed to be cleaned at least weekly, and there was no indication that the resident had refused cleaning. The facility's policy specified that housekeeping was responsible for checking the temperature and cleanliness of residents' refrigerators, but this was not followed in this instance.
Failure to Maintain Kitchen Refrigerator in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the only refrigerator in the kitchen in safe operating condition, as the door latch was broken and the refrigerator door would not close or seal properly. Observations confirmed that the refrigerator door remained slightly open due to the broken latch. Multiple staff interviews acknowledged that the refrigerator was not sealing, which could result in food not being held at the appropriate temperature and potentially spoiling. The Dietary Supervisor stated that the issue with the refrigerator door had been reported previously but had not been fixed. Record review of the facility's Refrigerators and Freezers Policy indicated that supervisors are required to inspect refrigerators monthly for maintenance needs and initiate necessary repairs immediately. Despite this policy, the refrigerator's broken latch had not been addressed, and the problem persisted until it was observed during the state inspection. The administrator confirmed that the issue was only reported to her as of the inspection date and had not been previously communicated by the kitchen staff.
Inaccessible Bathroom Call Light Puts Resident at Risk
Penalty
Summary
A deficiency was identified when a resident's bathroom call light pull string was found wrapped up and inaccessible from the floor, making it impossible for the resident to reach the call system in the event of a fall. The resident, who was cognitively intact and independent with toileting hygiene and transfers, was at risk for falls and had a care plan intervention to ensure the call light was within reach. Despite this, during an observation, the call light was not accessible as required. Interviews with facility staff revealed that maintenance was responsible for ensuring call lights were in working order and that strings were long enough to be accessible. The maintenance staff member, who was new to the facility, acknowledged the issue and stated she would address it. The DON confirmed maintenance's responsibility for call lights and recognized that an inaccessible call light would prevent a resident from calling for help if needed. The facility's policy required that call lights be within reach and accessible to residents.
Failure to Appoint Licensed Administrator for Facility Management
Penalty
Summary
The facility's governing body failed to appoint a state-licensed Administrator responsible for the management of the facility from 3/25/2025 through the surveyor's exit on 5/1/2025. During this period, the Director of Nursing (DON) confirmed that there was no full-time Administrator in place, and that the MDS nurse, who had recently obtained her administrator license, was intended to fill the position but had not yet received or accepted an official offer. The MDS nurse was not present at the facility daily, as she had permission to work from home on some days, and staff were reporting to the DON in the absence of an Administrator. Interviews with the MDS nurse, Business Office Manager (BOM), and Regional Director of Operations (RDO) all confirmed that the facility had been without an Administrator since the previous Administrator's departure. The MDS nurse stated she was waiting for an offer letter and had not officially accepted the position. Facility policy requires the governing body to appoint a licensed Administrator responsible for facility management, but this had not occurred during the period reviewed.
Failure to Prevent Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff in two separate incidents involving two residents. In the first incident, a female resident with chronic obstructive pulmonary disease, pseudobulbar affect, and major depressive disorder, who was totally dependent on staff for bathing, was subjected to derogatory comments by a CNA. The CNA told the resident she was 'stinky' and needed to shower, and further commented about the odor in the resident's room and the need to air it out. The resident expressed feeling offended and sad about the comments, as documented in a psychiatric assessment, although she stated she would be okay. In the second incident, a male resident with type 2 diabetes, insomnia, and depression, who had a care plan addressing potential verbal aggression, was involved in a verbal altercation with a cook. The cook was witnessed screaming at the resident, using profane language, and expressing frustration about the resident's behavior. The incident was witnessed by the business office manager, who intervened and later reported the cook's continued yelling. The resident acknowledged the incident but stated he was no longer affected by it, and the cook was subsequently terminated. Both incidents were corroborated by witness statements and interviews with staff and residents. The facility's policy prohibits abuse or neglect in any form and requires immediate reporting and assessment of any allegations. However, in these cases, staff failed to prevent verbal abuse, resulting in residents being subjected to inappropriate and offensive language by facility employees.
Failure to Appoint Licensed Administrator
Penalty
Summary
The governing body of the facility failed to appoint a state-licensed Administrator responsible for managing the facility from December 13, 2024, to February 12, 2025. During this period, the facility was without a full-time Administrator, which could potentially affect the health and safety of all residents. The Director of Nursing (DON) confirmed that the facility did not have a full-time Administrator and that an interim Administrator was hired but was not consistently present at the facility. The interim Administrator started on February 12, 2025, and had only been at the facility about four times since her appointment, visiting approximately twice a week. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Business Office Manager (BOM), corroborated that the facility had been without an Administrator since December 2024. The DON reported that during the absence of an Administrator, she sought guidance from an Area Director of Operations (ADO) who was not licensed in Texas and other Administrators she knew. The interim Administrator acknowledged that she was unaware of the facility's lack of an Administrator before her start date and recognized the risk of missing critical compliance without an Administrator present. The facility's policy requires a licensed Administrator to manage the facility, which was not adhered to during the specified period.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services for two residents, leading to deficiencies in their care. Resident #6, who has dementia, paraplegia, and scoliosis, was not given scheduled baths or proper nail care. Observations revealed that her fingernails were long with a brown substance underneath, her skin was dry, and she had unwanted facial hair. The facility's records showed multiple instances where scheduled baths were not documented, indicating they were likely not provided. Similarly, Resident #7, diagnosed with generalized anxiety disorder and hypertension, did not receive scheduled baths or facial hair removal. Observations noted that she was picking at visible hair on her chin, which she expressed dislike for. The facility's records also showed missing documentation for her scheduled baths, suggesting they were not conducted as required. Interviews with staff, including CNAs and the ADON, revealed inconsistencies in documentation and communication regarding the provision of showers and personal care. The ADON admitted to issues with staff completing electronic charting and acknowledged that audits were not consistently conducted to ensure compliance with care schedules. The DON confirmed that the lack of documentation likely meant the showers were not given, and the Interim Administrator was unaware of these issues, indicating a need for improved staff education and oversight.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a hospice aide and two CNAs. The hospice aide did not wear a gown while providing a bed bath to a resident on enhanced barrier precautions, despite a sign on the resident's door indicating the need for such precautions. The aide admitted to not understanding the meaning of enhanced barrier precautions and did not seek clarification or assistance from facility staff. Two CNAs also failed to adhere to proper infection control practices while providing incontinent care to another resident. They did not wash or sanitize their hands before, during, or after the care, and one CNA did not change gloves when moving from dirty to clean areas. Both CNAs acknowledged their lapses in hand hygiene and glove use, recognizing the potential for cross-contamination and infection spread. The Director of Nursing, who serves as the Infection Preventionist, confirmed that staff, including contract workers, are required to follow enhanced barrier precautions and perform hand hygiene as per facility policy. The facility's policies on infection control and hand washing emphasize the importance of these practices in preventing the spread of infection, yet the observed deficiencies indicate a failure to consistently implement these protocols.
Inadequate Supervision and Security Measures Lead to Resident Elopements
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for residents, leading to two separate elopement incidents involving residents with cognitive impairments. One resident, diagnosed with Major Depressive Disorder and mild cognitive impairment, was identified as a high risk for elopement. Despite being placed in a secured unit, the resident managed to climb out of a window using a nail to open it, intending to go to a store. This incident occurred after the resident had previously attempted to elope, highlighting a pattern of wandering behavior that was not adequately addressed by the facility. Another resident, also diagnosed with Major Depressive Disorder and moderate cognitive impairment, managed to leave the facility through an unlocked door in the secured unit. This resident had a history of wandering and had been placed in the secured unit due to previous attempts to leave the facility unattended. The door's failure to lock properly allowed the resident to exit the building and walk to a nearby location before being found and returned by staff. Interviews with staff revealed inconsistencies in the monitoring and maintenance of security measures, such as door locks and alarms. Staff were unsure of the frequency of checks on these security features, and there was no documentation to confirm regular inspections. Additionally, observations noted that some windows lacked safety locks, and alarms were not always audible, further compromising the safety of residents in the secured unit.
Removal Plan
- Review facility records to identify residents at risk.
- Move unit staff onto floor and out of nurses station to provide safety and hall monitoring.
- Conduct a tour of secure unit to identify issues with secured doors, replace batteries of door alarms, check sound/volume, check and provide safety locking for windows, secure gate, and add to daily maintenance round sheet.
- Contact security to test mag lock on secured unit gate and exit doors for safety purposes.
- Monitor and document by RN manager or manager on duty.
- Start in-service for all staff regarding elopement risk and policies, maintaining a safe and secure facility, and monitoring of doors, door alarms, and windows.
- Inservice maintenance man 1:1 on safety monitoring and checking batteries in alarms, mag locks on secure areas, and other protocol to prevent elopement.
- Add all findings to QA meeting for further review and recommendations.
Inadequate Call System Monitoring in Hall 400
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically in Hall 400. This deficiency was observed during a survey where the call lights were not visible or audible to staff, which could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. The surveyor noted that the call light system in Hall 400 was not adequately monitored, as the audible alarm was not heard at the 100/300 nurses' station, and the call light bulb was not functioning above the doorway of an unoccupied room. Interviews with staff revealed that the monitoring of the call light system was inconsistent. Staff members reported that they relied on random visual checks of the call lights above doorways and that the audible alarms were faint. The staff took turns monitoring the hallway between rounds, but there were times when it might take 15 to 20 minutes before someone noticed an activated light. This lack of a reliable call system monitoring process posed a risk to residents, as they might have to wait for longer periods for assistance. Residents on Hall 400, including those with cognitive impairments and those requiring assistance with activities of daily living, were encouraged to use the call bell for assistance. However, the facility's failure to ensure a functioning and monitored call system compromised the residents' ability to receive timely help. Despite the deficiency, residents interviewed during the survey reported not experiencing long waits for assistance, and there were no recorded incidents of falls or injuries due to unanswered call lights during the review period.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment across multiple areas, including the entrance foyer, shower rooms, and hallways. Observations revealed significant issues such as water-damaged and crumbling sheetrock in the entrance foyer, a broken and splintered door in the 100 hallway shower room, and unsecured cleaning agents accessible to residents. Additionally, the 300 hallway had chipped paint and exposed sheetrock, while the 500 and 800/900 hallways had unsecured supply rooms with sterile supplies accessible to residents and visitors. Interviews with staff highlighted awareness of these issues but indicated a lack of timely resolution. The Maintenance Man acknowledged the need for door replacement and securing supply rooms but cited difficulties in obtaining materials and prioritizing tasks. The DON and MDS Nurse expressed concerns about the potential for contamination and tampering with supplies due to the lack of locks. The Corporate Maintenance Man admitted to not maintaining a log of outstanding facility needs, which may contribute to the ongoing deficiencies. The facility's policy from 2001 emphasized providing a safe and homelike environment, yet these observations and interviews indicate a failure to uphold this standard.
Failure to Maintain Safe Environment Due to Detached Baseboard
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for two residents, as observed during a survey. The baseboard in the room shared by the two residents was detached from the wall over a period of several days. This issue was first observed on December 9, 2024, and remained unresolved by December 11, 2024. The residents involved had severe cognitive impairments, with BIMS scores indicating severe impairment in thinking, and both required substantial assistance with transfers and used wheelchairs. The care plans for both residents highlighted their risk for falls and the need to keep areas free of clutter. The issue with the baseboard was known to the facility staff, as a CNA reported noticing the problem the previous month and informed a housekeeper, who was supposed to notify the Maintenance Supervisor. The maintenance log indicated that the problem was identified on October 4, 2024, but had not been addressed by the Maintenance Supervisor, who acknowledged awareness of the issue but prioritized other tasks. The Maintenance Supervisor did not perceive the detached baseboard as a risk to the residents, despite the CNA's concern that it could cause residents to trip or fall. The facility's policy, revised in April 2021, stated that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inaccurate Medication Records and Documentation
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident, leading to discrepancies in the medication administration records (MAR). The resident, who had a diagnosis of major depressive disorder and moderately impaired cognition, had medications discontinued on a specific date. However, the MAR did not reflect the discontinuation, and medications were still documented as administered even when the resident was out of the facility. Interviews with the nursing staff revealed that there were lapses in updating the MAR and flagging it when the resident was hospitalized. One nurse admitted to a data entry error, while another acknowledged failing to update the MAR to indicate the discontinuation of medications. The Director of Nursing confirmed that all nurses had been trained on proper charting and recording but expected accurate documentation to prevent negative outcomes. The facility's policies on medication administration and charting emphasize the importance of accurate documentation and communication among the interdisciplinary team. Despite these policies, the failure to update the MAR and accurately document the resident's status and medication orders could lead to improper care due to inaccurate records.
Inadequate Tracheostomy Care and Training Deficiency
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheostomy care and tracheal suctioning. The resident, who had quadriplegia and a tracheostomy, expressed concerns about the facility's ability to manage his trach care adequately. Observations revealed that LVN C reused a single-use suction catheter, did not employ sterile technique, and used tap water during tracheal suctioning, which is against professional standards of practice. Interviews with LVN C and other staff members indicated a lack of proper training and competency in tracheostomy care. LVN C admitted to not receiving adequate training or a competency check-off at the facility, and she was unsure of the correct procedures. Other staff members also reported insufficient training, relying on previous experience rather than formal instruction at the facility. The DON acknowledged that training was supposed to be conducted on hire and annually, but recent staff changes and management turnover had disrupted this process. The facility's policy required aseptic technique and sterile gloves during tracheostomy care, but these standards were not met. The Medical Director emphasized the risk of infection and aspiration if proper care was not provided. Despite the facility's policy and the DON's assertion that training should occur annually, the lack of consistent and comprehensive training led to improper care, placing the resident at risk for respiratory complications.
Deficient Nursing Competencies and PPE Use
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care to residents, as evidenced by multiple observations and interviews. CNA A did not properly clean a resident's penis during incontinent care, and both CNA A and CNA B failed to wear personal protective equipment (PPE) for enhanced barrier precautions. Additionally, LVN D did not wear PPE during wound care, and LVN C did not use sterile technique during tracheostomy care and suctioning. These actions were observed during care provided to residents with severe cognitive impairments and complex medical needs, including a resident with a tracheostomy and another with a stage 3 pressure wound. The report highlights that CNA A and CNA B were not trained on enhanced barrier precautions, which contributed to their failure to use PPE during care. The facility's Administrator and Director of Nursing (DON) acknowledged that the staff had not been trained on these precautions, and the DON admitted that Resident #2's wound was not considered chronic, which may have influenced the lack of precautions. Furthermore, LVN D and LVN C both reported not receiving adequate training or competency evaluations for the care they were providing, with LVN C expressing discomfort and lack of confidence in her skills due to insufficient training. The facility's policies on tracheostomy care and competency evaluations were not effectively implemented, as evidenced by the lack of proper training and competency checks for the staff involved. The DON admitted that training was not as extensive as it should be, and the facility had not conducted recent training sessions with a respiratory therapist. The absence of consistent nurse management and the influx of new staff further exacerbated the issue, leading to deficient practices that could place residents at risk for infection and harm.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in various areas, including two hallways, a nurse's station, and the rooms of two residents. Observations revealed gnats flying around Resident #1's open tracheostomy during care, and multiple gnats were seen on the resident's chair cushion. Resident #8's room also had gnats due to a chicken box left in the trash can, which was observed by a family member who expressed concern about the unsanitary conditions affecting the resident's ability to eat peacefully. Further observations noted gnats in the 100 and 300 hallways and at the nurse's station, where a CNA was seen swatting at them. An ice chest at the nurse's station was found to contain a gnat in the ice. Interviews with staff and family members indicated that the gnat problem had persisted for weeks, with inconsistent pest control measures being reported. The maintenance man and pest control representative confirmed that spraying for gnats was not part of the regular pest control service, and documentation of such treatments was lacking. The facility's pest control policy, revised in October 2023, mandates an effective pest control program and daily removal of trash, which was not adhered to, as evidenced by the presence of gnats and the accumulation of trash in resident rooms. The Director of Nursing and Administrator acknowledged the issue, noting that pest control had been called to address the problem, but the measures taken were insufficient to prevent the infestation from affecting the residents' living conditions.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper infection control practices. Specifically, CNA A and CNA B did not wear appropriate personal protective equipment (PPE) while providing incontinent care to a resident, and CNA B failed to sanitize or wash her hands between glove changes. Both CNAs were unaware of enhanced barrier precautions and had not received training on them. Additionally, LVN D did not wear a gown for enhanced barrier precautions while performing wound care on another resident. This resident had a stage 3 pressure wound, and the care plan did not address enhanced barrier precautions. LVN D also reported not being aware of these precautions and had not been trained on them. Furthermore, LVN C did not use appropriate sterile techniques while performing tracheostomy care and suctioning for a resident. The LVN used non-sterile gloves and did not maintain a sterile field, which is required for such procedures. Despite being employed at the facility for four months, LVN C was unsure of the correct steps for trach care, indicating a lack of adequate training and competency evaluation.
Failure to Provide Privacy Covers for Urinary Drainage Bags
Penalty
Summary
The facility failed to ensure the dignity and respect of two residents by not providing privacy covers for their urinary drainage bags. Resident #1, a male with quadriplegia and an indwelling urinary catheter, was observed in the dining room with his urinary drainage bag exposed, lacking a privacy cover. His comprehensive care plan specifically included an intervention to ensure the catheter was placed in a privacy bag, which was not adhered to. Similarly, Resident #5, a female with epilepsy and a catheter, was observed in her room with her urinary drainage bag visible to passersby due to the absence of a privacy cover. Her baseline care plan did not list any interventions for the catheter, and she reported that no staff had informed her about the use of a privacy cover. Interviews with the facility's Administrator and Director of Nursing (DON) revealed an expectation that privacy bags should be used to maintain residents' dignity. The facility's policy on catheter care, dated 2017, also stipulated the use of covers for catheter drainage bags to preserve resident dignity. Despite these policies and expectations, the lack of privacy covers for the urinary drainage bags of Residents #1 and #5 was observed, indicating a failure to uphold the residents' rights to a dignified existence as guaranteed by federal and state laws.
Failure to Provide Scheduled Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary personal hygiene services for two residents, both of whom were dependent on staff for activities of daily living (ADLs) such as bathing and grooming. Resident #6, who has diagnoses including type 2 diabetes and quadriplegia, was observed with long, overgrown fingernails with a black substance underneath and dry, scaly skin. The records indicated that Resident #6 received only two documented baths in September and one in October, despite being scheduled for showers three times a week. Interviews with staff revealed that there were issues with residents not receiving showers, and the Director of Nursing (DON) and Administrator were aware of these issues. Resident #1, also dependent on staff for ADLs due to quadriplegia and other medical conditions, was found with long fingernails with a brown substance underneath and unkempt facial hair. The records showed only one documented shower refusal in October, and the resident reported not receiving a bath since returning from the hospital. Staff interviews confirmed that Resident #1 was often in and out of the hospital and had not been given a bath by the current staff. The DON acknowledged a staff shortage on the 2 pm - 10 pm shift, which led to a change in the shower schedule. The facility's policy on activities of daily living, dated May 2017, states that residents should have their ADL needs met. However, the observations and interviews indicate that the facility did not adhere to this policy, resulting in residents not receiving adequate personal hygiene care. The Administrator and DON were aware of the issues and had attempted to address them by adjusting the shower schedule, but the deficiencies persisted, affecting the residents' dignity and potentially their health.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident #6, who was admitted with conditions including type 2 diabetes and quadriplegia, was at risk for pressure ulcers but did not have any unhealed pressure ulcers upon admission. However, the facility did not conduct weekly skin assessments for Resident #6 during specified weeks, and the resident reported infrequent wound care, indicating a lack of consistent monitoring and treatment. Resident #7, admitted with a displaced intertrochanteric fracture and Alzheimer's disease, also experienced inadequate skin assessments. The facility's records showed that a skin assessment noted bruising and incisions but did not identify a hardened area on the resident's right heel until it was brought to the attention of the staff by a sitter. This oversight suggests a failure in the facility's communication and monitoring systems, as the sitter had to alert the staff to the condition, which had worsened since the resident's admission. Interviews with facility staff, including a CNA, LVN, and the DON, revealed systemic issues with the completion and documentation of weekly skin assessments. The DON acknowledged an ongoing issue with missed assessments, and the Administrator confirmed the risk of unnoticed wounds due to the lack of regular assessments. The facility's policies required weekly skin assessments and documentation, but these were not consistently followed, leading to the deficiencies observed in the care of Residents #6 and #7.
Deficiencies in Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to deficiencies in incontinent and catheter care. Resident #2, a male with severe cognitive impairment and incontinence, did not receive proper perineal care. During an observation, CNA A and CNA B were seen performing incontinent care on Resident #2, but CNA A did not clean the penis properly, failing to clean the tip and the entire shaft. Despite being trained on perineal care for males, CNA A admitted to not performing the task correctly. Resident #5, a female with an indwelling catheter, was observed with her urinary drainage bag tubing lying on the floor and without a securement device to anchor the catheter. The facility's policy requires that catheter tubing be secured and not touch the floor to prevent infections. The Director of Nursing and the Administrator acknowledged that improper care could lead to infections and trauma, emphasizing the importance of following proper procedures.
Failure to Update Facility-Wide Assessment Annually
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past year, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. The last update to the Facility Assessment was in February 2023, and it had not been reviewed or updated since then, despite the requirement for an annual review. This oversight was identified during a record review and interviews conducted by surveyors. During an interview, the Administrator, who had been employed at the facility since late July 2024, acknowledged that the facility assessment had not been updated since February 2023. Although she updated the first page to reflect a new Medical Director in August 2024, no other updates were made. The Administrator admitted that she was aware of the need for an annual update and recognized that the assessment should have been updated before her employment. The facility's policy, revised in October 2023, also indicated that the assessment should be conducted and updated annually.
Failure to Orally Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were informed orally of their rights, as evidenced by interviews and record reviews. Eight residents reported during a group meeting that the Activity Director had not reviewed or explained their rights to them. Record reviews of monthly resident council meeting minutes revealed that resident rights had not been reviewed over the past five months. The Activity Director admitted to not reviewing the list of resident rights with the residents, stating she was unaware that it was required. She mentioned that she would discuss specific rights only if a resident brought up an issue involving a right. The Administrator confirmed that residents receive a copy of their rights upon admission but acknowledged that the list of rights had not been reviewed with the residents during their stay. The facility's policy on resident rights, last revised in 2016, did not address the need for orally explaining these rights to the residents. This lack of ongoing communication about resident rights could potentially impact the residents' quality of life and awareness of their rights.
Failure to Follow Menu and Ensure Proper Portion Sizes
Penalty
Summary
The facility failed to ensure the menu was followed for two lunch meals, resulting in residents not receiving the appropriate portions and types of food as per their dietary requirements. On 04/22/24, a resident on a pureed diet did not receive pureed bread as indicated on the dietary spreadsheet. The dietary manager (DM) admitted that the pureed bread might have been mixed with the vegetables, but no adjustments were made to the vegetable serving size to account for this. On 04/23/24, the facility used incorrect utensils for serving food, leading to improper portion sizes. Regular and mechanical diets received only half portions of bread, and pureed diets did not receive pureed bread at all. Additionally, substitutions were made without following recipes or proper measurements, such as using black beans instead of fried okra and creamed corn instead of sauerkraut, which were not pureed to the correct consistency. During observations in the kitchen on 04/23/24, it was noted that the DM and Cook A were not following the planned menu or using the correct serving utensils. Regular sliced bread was used instead of Texas toast, and cake with frosting was substituted for apple crisp. The DM attempted to puree various food items but failed to achieve the proper consistency, leading to further substitutions. Cook A was observed serving food in a haphazard manner, not filling the serving utensils adequately, and not ensuring the correct portion sizes. The DM did not check the utensils used for service or ensure the foods served were appropriate, and there was a lack of proper communication and coordination among the kitchen staff. The deficiencies in meal preparation and service were further highlighted when a dietary aide reported that a resident who was supposed to receive large portions did not get them because there was not enough food. The DM seemed resigned to the situation, indicating a lack of control and oversight in the kitchen operations. The facility's failure to follow the menu and ensure proper portion sizes and food consistency could place residents at risk of not having their nutritional needs met.
Unsanitary Food Handling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Observations revealed multiple instances of unsanitary practices, including a microwave with food debris and splatters, a bulk flour bin with a measuring cup stored inside, and a dietary manager (DM) who dropped a thermometer into pureed meat and continued to use it after wiping it with her bare hand. Additionally, Cook A was observed touching the inside of plates and food with her gloved hands, not wearing an apron, and using her body to keep plates on the tray line. Dietary Aide (DA) B was seen touching the inside of plates with her bare hand and placing bread on top of food without using a utensil. Cook A also returned food that had spilled onto the prep area back to the pan of food on the steam table. These observations indicate a lack of adherence to sanitary food handling practices, which could place residents at risk of foodborne illness. The DM was not monitoring the food service line and was unaware of the unsanitary activities taking place. The report highlights specific instances where staff failed to follow proper handwashing and food handling procedures, as outlined in the Food Code 2013, which emphasizes the importance of clean hands and arms to prevent the transmission of foodborne pathogens.
Inaccurate PASRR Screenings for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for two residents. Resident #33, a male with major depressive disorder, was admitted with diagnoses including major depressive disorder with behaviors. His PASRR Level 1 Screening inaccurately indicated no evidence of mental illness, despite his medical records showing he was receiving antidepressant and antipsychotic medications. Similarly, Resident #35, a male with a mood disorder, was admitted with diagnoses including bipolar disorder. His PASRR Level 1 Screening also inaccurately indicated no evidence of mental illness, despite his medical records showing he was receiving antidepressant and antipsychotic medications. During interviews, the Director of Nursing (DON) and the MDS Nurse confirmed that the MDS department was responsible for reviewing PASRR Level 1 Screenings. The MDS Nurse admitted that the inaccuracies were not addressed due to the training of a new MDS Nurse at the time of the residents' admissions. The MDS Nurse acknowledged that the state designated authority should have been notified of the inaccuracies to ensure the residents received the correct resources and services.
Inaccurate Daily Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post accurate daily nurse staffing information for the 6 AM-2 PM shift on three consecutive days. Observations on 04/22/2024, 04/23/2024, and 04/24/2024 revealed discrepancies between the posted nurse staffing reports and the actual hours worked by registered nurses (RNs) and licensed vocational nurses (LVNs) directly responsible for resident care. The posted reports inaccurately included the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set (MDS) Nurse in the count of nurses providing direct resident care, despite these individuals not performing direct care duties for the full duration of their shifts. Specifically, the DON did not provide direct resident care, the ADON only performed direct care for 2-3 hours, and the MDS Nurse did not perform direct care at all. This misrepresentation was confirmed through interviews and a review of the nursing schedules, which showed that only 2 LVNs on the north side and 1 LVN on the south side were assigned to direct resident care for the 6-2 shift on the reviewed dates, with no RN assigned to direct care duties. During an interview, the DON admitted to including herself, the ADON, and the MDS Nurse in the direct care count based on her understanding of how to complete the staffing reports. This practice resulted in the posting of inaccurate staffing information, which could mislead residents, their families, and visitors regarding the actual number of nursing staff available for direct resident care. The facility's policy on staffing requires accurate posting of direct care staff numbers and hours, which was not adhered to in this instance.
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What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Castle Pines Health And Rehabilitation | 0.3 mi | ★★★★★ | 1 | 1 |
| Larkspur | 0.5 mi | ★★★★★ | 3 | 0 |
| Parkwood In The Pines | 0.8 mi | ★★★★★ | 11 | 0 |
| Pinecrest Retirement Community | 2.2 mi | ★★★★★ | 2 | 0 |
| Southland Rehabilitation And Healthcare Center | 4.1 mi | ★★★★★ | 9 | 0 |
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