Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Hacienda De Paz Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility did not ensure that residents were seen by a physician at the required intervals, with several residents missing timely in-person physician visits both during the first 90 days after admission and in the ongoing care period. Documentation showed that some residents with complex medical needs and cognitive impairments were not seen as required, and staff interviews revealed a lack of awareness of the correct regulatory schedule for physician visits.
The facility failed to ensure accurate resident assessments, with multiple instances where MDS documentation did not reflect actual skin conditions, medication use, or primary diagnoses. Several residents had discrepancies between their care plans, medication records, and MDS entries, including missing documentation of pain, antiplatelet, and antidepressant medications. Additionally, a resident was incorrectly coded regarding mental illness status and primary diagnosis on the MDS and PASARR screening, despite clear medical records. Staff interviews confirmed these inaccuracies and inconsistent review processes.
A resident with multiple serious health conditions and severe cognitive impairment had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order that was not valid due to a missing physician signature. Although the resident's representative requested DNR status and staff documented this in the electronic record, the required physician signature was not obtained, and staff acknowledged the deficiency during interviews. The facility's process for finalizing OOH-DNR orders involved multiple departments and was delayed by physician availability, resulting in the resident's end-of-life wishes not being legally documented.
A resident with severe cognitive impairment and on anticoagulant and antiplatelet therapy developed multiple bruises over several weeks, which were documented by nursing staff but not reported to the physician as required by care plan and facility policy. The DON and the resident's physician confirmed that the physician was not notified of the bruising until much later, despite clear protocols for reporting significant changes in condition.
A resident with severe cognitive impairment and on anticoagulant therapy developed multiple unexplained bruises on her arms and legs over several weeks. Despite documentation of these bruises in weekly skin assessments, staff did not promptly report the findings to the charge nurse, physician, or DON as required by policy. The failure to report and investigate these injuries of unknown source resulted in a deficiency related to timely reporting and investigation of suspected abuse, neglect, or injury.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple unexplained bruises on both arms. Staff acknowledged the resident bruised easily and used protective sleeves, but did not complete an incident report or notify the DON or physician as required. The facility did not conduct a thorough investigation or report the incident to the state agency within the mandated timeframe, resulting in a deficiency for failing to respond appropriately to potential abuse or neglect.
A resident with multiple diagnoses and on anticoagulant therapy did not receive all three physician-ordered guaiac stool tests, with only two documented in the medical record. Additionally, new onset bruising was not reported to the physician as required by the care plan and facility policy. The DON confirmed the missing test result and lack of reporting during the survey.
The facility did not ensure that controlled substance reconciliation logs for two medication carts were consistently signed by staff during shift changes, as required by policy. Although medication counts matched records, missing signatures on the logs indicated that the reconciliation process was not fully completed by nursing staff.
Surveyors found a loose, unlabeled pill in one medication cart and observed another cart left unlocked and unattended. Nursing staff and the DON confirmed that all medications should be properly labeled and carts should remain locked when unattended, in accordance with facility policy.
A resident with multiple health conditions and on anticoagulant and aspirin therapy had abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count. Staff did not promptly notify the physician or document the abnormal findings, and the physician was not made aware until weeks later, resulting in delayed follow-up testing and incomplete collection of ordered stool samples.
Surveyors found multiple opened and undated food items in the nourishment room fridge, including milk, soup, cheese, and meat, with the Dietary Manager unaware of their origin. The nourishment room, accessible to staff and families, is supposed to follow kitchen policies requiring opened food to be dated and properly stored, but these standards were not met.
A nurse failed to follow proper hand hygiene protocols during wound care for a resident with stage 4 pressure ulcers. After washing hands, the nurse touched the privacy curtain and door handle with bare hands before putting on gloves and continuing wound care, contrary to the facility's infection control policy. Both the nurse and DON acknowledged that this could result in contamination.
A resident with severe cognitive impairment and a history of wandering was not adequately supervised, resulting in a witnessed incident where he sexually abused another cognitively impaired resident. Despite prior behavioral concerns and care plans noting risks, the facility's monitoring measures were insufficient to prevent the abuse.
Two residents with significant medical conditions were transported to medical appointments in their wheelchairs across a street, rather than being taken in the facility van as per policy. One experienced pain due to her condition, while the other felt embarrassed and was not given a choice in transportation method. Staff interviews confirmed that residents were not routinely asked for their preferences, and required transportation procedures were not followed.
A staff member misappropriated $891 from a cognitively impaired resident by making unauthorized Cash App withdrawals from the resident's bank card. The incident was discovered when the Business Office Manager found insufficient funds in the resident's account, leading to an internal investigation and police involvement. Staff interviews confirmed awareness of abuse and misappropriation protocols, and no other residents reported similar incidents.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks for missed care. One resident's cardiac pacemaker was not documented, despite being a significant part of his medical history, while another resident's history of falls was omitted. These omissions were due to oversight by a new MDS nurse, highlighting the importance of accurate documentation as emphasized by facility staff and policies.
A resident with a cardiac pacemaker did not receive the required apical pulse monitoring as per their care plan. RN C, responsible for the resident's care, used a machine and cuff for vital signs and was unaware of the pacemaker, despite initialing off on the apical pulse check. The resident confirmed that only the doctor listened to his heart, and the DON acknowledged the importance of apical pulse monitoring for such residents.
A resident with a history of stroke, atrial fibrillation, heart failure, and dysphasia received peri and wound care without proper hand hygiene by CNA D and RN C. Both staff members failed to sanitize their hands between glove changes, risking cross-contamination. The DON confirmed the necessity of hand hygiene to prevent infections.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals as mandated by regulation. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission, and ten additional residents were not seen at least once every 60 days thereafter. Documentation reviewed for these residents showed significant lapses in the required physician visits, with some residents only being seen once or not at all within the required timeframes. The medical records for these residents included diagnoses such as pneumonia, diabetes, acute metabolic acidosis, dependence on renal dialysis, heart disease, fractures, osteoporosis, depression, and other chronic conditions. Many of these residents were also noted to have severe or moderate cognitive impairment and were receiving complex medication regimens, including antipsychotics, antidepressants, anticonvulsants, and hypoglycemics. Interviews with facility staff revealed a lack of awareness and understanding of the regulatory requirements for physician visit frequency. The DON confirmed that nurse practitioners were not utilized and that physician assistants assisted only once a week. The Administrator stated that the facility followed a schedule of physician visits every 30 days for new admissions and every 90 days thereafter, which does not align with the regulatory requirement of every 60 days after the first 90 days. The Medical Director also stated he was not aware of the 60-day requirement and believed visits every three months were sufficient. He relied on nursing staff to communicate any patient problems and had not discussed visit frequency with the DON or Administrator. Record review and staff interviews confirmed that the facility did not have a clear policy or consistent practice to ensure compliance with the required physician visit schedule. The documentation provided by the facility often included hospital records or telehealth/telephone visits instead of in-person physician visits, and in some cases, no recent physician visit could be found in the medical record. The lack of timely physician visits was identified for residents with significant medical and cognitive needs, and the surveyors noted that these failures could place residents at risk for medical conditions not being identified and care needs not being met.
Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation and medication records. For several residents, the MDS assessments did not include accurate information regarding skin conditions, medication usage, and primary diagnoses. For example, one resident's significant change MDS incorrectly documented the presence of unhealed pressure ulcers, despite care plans and physician orders indicating ongoing skin care interventions. Another resident's quarterly MDS omitted documentation of pain and antiplatelet medication, even though these medications were actively prescribed and administered, as shown in the Medication Administration Records (MAR) and care plans. Additional deficiencies were observed in the documentation of antidepressant and antiplatelet medication use for other residents. In one case, a resident's MDS failed to reflect the use of both antidepressant and antiplatelet medications, despite active orders and administration records confirming their use. Similarly, another resident's MDS did not document the use of prescribed antidepressant medications, even though the care plan and MAR indicated regular administration of these drugs. These omissions were confirmed through interviews with the MDS Case Manager and Director of Nursing (DON), who acknowledged the importance of accurate MDS documentation and the expectation that staff use available medical records to complete assessments. The facility also failed to accurately code a resident's primary diagnosis and mental illness status on the MDS and PASARR Level 1 Screening. One resident was incorrectly coded with a primary diagnosis of dementia and no mental illness, despite having a documented diagnosis of bipolar disorder. Interviews with facility staff revealed a lack of clarity regarding the process for verifying and correcting PASARR assessments, as well as uncertainty about the identification of primary versus secondary diagnoses. Facility policies required review of PASARR forms for accuracy prior to admission, but documentation and interviews indicated this process was not consistently followed.
Failure to Obtain Physician Signature on OOH-DNR Order
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was valid, as the required physician's signature was missing from the form. The resident in question was an elderly male with multiple significant medical conditions, including acute kidney failure, dependence on renal dialysis, hypertension, hyperlipidemia, and heart failure. He was severely cognitively impaired and required regular dialysis treatments. Documentation showed that the resident's representative had requested DNR status, and the facility's records, including the electronic profile and care plan, reflected a DNR order. However, the OOH-DNR form lacked the physician's signature, rendering it invalid according to state requirements. Interviews with facility staff revealed a lack of clarity and consistency in the process for obtaining and finalizing OOH-DNR orders. Nursing staff, the ADON, and the SW all confirmed that the resident was listed as DNR in the electronic record, but upon review, the OOH-DNR form was found to be incomplete due to the missing physician signature. The SW, who was responsible for auditing OOH-DNR forms, acknowledged the deficiency and stated that the facility was still waiting for the physician to sign the document. The DON and other staff described a process in which the OOH-DNR form was initiated at admission, signed by the resident or representative, and then routed through various departments before being presented to the physician for signature. Delays in obtaining the physician's signature were attributed to the physician's availability and the process of delivering the form to the physician's office. Despite the lack of a valid OOH-DNR form, staff indicated that they would honor the family's wishes based on the signed request for DNR status, even though the form was not legally valid without the physician's signature. The Medical Director stated that the OOH-DNR should be signed within 24 hours of the order being entered into the electronic record, and that without the physician's signature, the resident would be considered full code. Facility policy and state guidance both require a properly executed OOH-DNR form, including all necessary signatures, for the order to be valid and honored by health professionals.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically the development of multiple bruises over several weeks. The resident, an elderly female with diagnoses including sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and antiplatelet therapy, which increased her risk for bleeding and bruising. Despite care plan and physician orders requiring staff to monitor for and report signs of bruising or bleeding, documentation showed that a nurse recorded the presence of multiple bruises on the resident's arms and legs on three separate weekly skin assessments but did not notify the physician as required. Observations and interviews confirmed that the resident had extensive bruising on both arms, which had been present for about 15 days. The resident was unable to recall the cause of the bruises and was noted to have severe memory impairment. Staff interviews indicated that the resident was known to bruise easily, and protective measures such as geri sleeves were used. However, the nurse responsible for the resident's care acknowledged that she had not communicated the bruising to the physician, despite being aware of the ongoing issue and the care plan's instructions. The Director of Nursing (DON) confirmed that the nurse should have completed an incident report and notified both the DON and the physician about the bruising. The resident's primary physician stated he was not made aware of the recent bruising until notified by the DON, and he indicated that he would have provided different medical orders had he been informed earlier. Facility policy required timely physician notification and documentation of significant changes in resident status, which was not followed in this case.
Failure to Timely Report and Investigate Unexplained Bruising
Penalty
Summary
A resident with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia was noted to have multiple bruises on her upper and lower extremities over several weeks. The resident was on anticoagulant and antiplatelet therapy, and her care plan included specific interventions to monitor and report signs of bleeding or bruising. Despite repeated documentation of bruising in weekly skin assessments, there was no evidence that these findings were promptly reported to the charge nurse, physician, or Director of Nursing (DON) as required by facility policy. The resident herself was unable to explain the origin of the bruises, and staff interviews confirmed that the bruising was known but not recently reported to appropriate authorities. Facility policy mandates that injuries of unknown source, especially those that are unexplained by the resident and are suspicious due to their extent or location, must be identified, investigated, and reported to the DON, administrator, state, and/or adult protective services. In this case, the LVN acknowledged not reporting the bruises, and the DON confirmed that an incident report should have been completed and notifications made. The failure to report and investigate the bruising as potential abuse, neglect, or injury of unknown source constitutes a deficiency in timely reporting and investigation as required by regulation and facility policy.
Failure to Investigate and Report Unexplained Bruising
Penalty
Summary
The facility failed to thoroughly investigate and report unexplained bruising found on a resident who was severely cognitively impaired and taking anticoagulant and antiplatelet medications. The resident was observed with multiple dark purplish bruises on both arms, extending from the knuckles to the upper arms, and was unable to explain the cause of the bruising. Staff interviews confirmed that the resident was known to bruise easily, and protective arm sleeves were used as an intervention. However, there was no evidence that an incident report was completed, nor was there documentation of timely notification to the Director of Nursing (DON) or the resident's physician regarding the bruising as required by facility policy. Record reviews showed that the resident had a history of multiple bruises documented during weekly skin assessments, but these findings were not escalated for further investigation. The DON confirmed that staff should have reported the bruising, completed an incident report, and notified the physician. The facility's policy requires that any unexplained injury, especially when the source is unknown or the resident cannot explain it, must be identified, investigated, and reported as a potential case of abuse or neglect. Despite the presence of multiple bruises over time and the resident's inability to provide an explanation, the facility did not initiate a thorough investigation or report the findings to the state survey agency within the required five working days. This lack of action was contrary to both facility policy and regulatory requirements, resulting in a deficiency for failing to respond appropriately to alleged violations of abuse, neglect, or mistreatment.
Failure to Complete Ordered Guaiac Tests and Report Bruising per Care Plan
Penalty
Summary
The facility failed to ensure that services provided or arranged, as outlined in the comprehensive care plan, met professional standards of quality for a resident with multiple medical conditions, including sepsis, cognitive decline, atherosclerotic heart disease, and dementia. The resident was on aspirin and anticoagulant therapy, with care plan interventions requiring immediate reporting of bruising and other signs of bleeding to the charge nurse and physician. Despite physician orders for three consecutive days of guaiac (fecal occult blood) testing following abnormal lab results indicating low hemoglobin, hematocrit, and red blood cell count, only two tests were completed and documented. The third required test was not found in the resident's medical records, and facility staff were unable to account for its absence. Additionally, the facility failed to report new onset bruising to the physician as directed in both the physician orders and the care plan. The facility's policy required timely notification and documentation of significant changes in resident status, including changes such as bruising, but there was no evidence that this was done. The Director of Nursing confirmed that only two guaiac test results were available and could not explain the missing third test. These failures were identified through interviews and record reviews conducted by surveyors.
Failure to Complete Controlled Substance Reconciliation Logs at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled for two of six medication carts reviewed. During observations of the 500/600 hall PO cart and the 100/200/600 hall PO cart, sample inventories of controlled medications showed no discrepancies between the quantities documented on individual controlled substance logs and the actual number of pills present. However, review of the comprehensive controlled medication reconciliation logs used for cart audits during shift changes revealed missing signatures: two signatures were absent on the 500/600 hall PO cart log, and one signature was missing on the 100/200/600 hall PO cart log. Interviews with nursing staff and facility leadership confirmed the expectation that the controlled substance reconciliation logs should be signed by both the staff member relinquishing and the staff member taking control of the cart at each shift change. The facility's policy requires a physical inventory of all controlled medications at each shift change, conducted by two licensed nurses or a nurse and a qualified medication aide, with documentation on an audit record. The absence of required signatures indicated that the reconciliation process was not consistently followed as outlined in facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified two deficiencies related to medication storage and labeling. On the 300/400 hall medication cart, a loose, unlabeled pill was found in the bottom of a drawer during an observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the presence of an unlabeled pill meant staff could not identify the medication or determine for which resident it was prescribed. The DON and Administrator both stated their expectations that all medications should be accurately labeled, properly contained, and that there should be no loose pills in the carts. Additionally, the 500/600 hall medication cart was observed to be left unlocked and unattended. Staff interviews confirmed that the cart was assigned to two nurses and that it should never be left unlocked and unattended, as unauthorized individuals, including residents who wander, could access the medications. The DON reiterated that medication carts should always be locked when unattended to prevent unauthorized access. Facility policy also requires that medications and biologicals be stored securely and that medication carts be locked or attended by authorized personnel.
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for one resident. The resident, an elderly female with a history of sepsis, cognitive decline, atherosclerotic heart disease, and dementia, was on anticoagulant and aspirin therapy. Her care plan required immediate reporting of symptoms or lab findings indicating complications from these medications. On 4/10/25, laboratory results showed significantly low hemoglobin, hematocrit, and red blood cell count. Despite these abnormal findings, there was no documentation in the nursing progress notes between 4/10/25 and 4/25/25 indicating that the physician was notified of these results. The physician did not review the abnormal labs or provide further orders until 5/13/25, at which point a guaiac test was ordered. The facility subsequently collected only two of the three required stool samples for this test, and both were negative for occult blood. The Director of Nursing confirmed that staff should have immediately notified the physician of the abnormal labs and documented this action, but was unable to explain the delay in physician review or the incomplete collection of ordered tests. Facility policy required prompt physician notification and documentation for abnormal lab results, which was not followed in this instance.
Undated Opened Food Items Found in Nourishment Room Fridge
Penalty
Summary
Surveyors observed that the nourishment room fridge contained multiple opened food items that were not dated, including a bottle of chocolate milk, containers with soup-like substances, a to-go box, an item wrapped in foil, cheese slices in plastic wrap, and a container of meat. These items appeared to have been previously opened and were not labeled with dates, contrary to facility policy. The Dietary Manager confirmed responsibility only for snacks placed in the fridge by dietary staff, which are labeled and dated daily, but was unaware of the origin or status of the other items found during the inspection. Further interviews revealed that the nourishment room is accessible to all staff and families, with no code required for entry, and is intended for resident use only. The Administrator stated that the nourishment room is subject to the same policies as the kitchen, which require opened food packages to be stored in closed containers or sealed bags and dated when opened. The presence of undated, opened food items in the fridge indicated a failure to follow these professional standards for food storage and safety.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to maintain proper hand hygiene during wound care for a male resident with two stage 4 pressure ulcers. The resident, who had severe cognitive impairment and a history of pressure injuries, required daily wound care as per physician orders. During an observed wound care procedure, the nurse washed her hands in the resident's bathroom but then touched the privacy curtain and door handle with her bare hands before donning gloves and continuing wound care. This sequence of actions was observed twice during the same procedure, once for each wound. The facility's infection control policy required hand hygiene before and after resident care, after contact with potentially contaminated surfaces, and after removing gloves. The nurse did not use hand sanitizer or rewash her hands after touching potentially contaminated surfaces before resuming wound care. Both the nurse and the Director of Nursing acknowledged during interviews that this practice could result in the transfer of germs to the resident, which is inconsistent with the facility's infection control protocols.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident who also had significant cognitive and behavioral issues. The incident involved a male resident with diagnoses including dementia, severe cognitive impairment (BIMS score of 5), and a history of wandering into female residents' rooms. Despite being identified as having the potential for physical behaviors related to dementia, the male resident was not adequately supervised, and on the date of the incident, he was found by a CNA in a female resident's room with his hand under her brief, touching her genital area. The female resident was also severely cognitively impaired, unable to consent, and had a history of stroke, aphasia, and hemiplegia. Prior to the incident, the male resident had been observed frequently entering other residents' rooms, particularly those of female residents, under the pretense of looking for his mother or wife. Observation logs indicated that he had been placed on intermittent increased observation at night due to his wandering, but these measures were not sufficient to prevent the incident. The female resident's care plan noted a psychosocial well-being problem related to a previous abuse allegation, but interventions focused on communication and referrals rather than enhanced supervision or protection from other residents. Staff interviews and record reviews confirmed that the facility had provided training on abuse, neglect, and misappropriation of property, and staff were aware of reporting protocols. However, the actions taken to monitor and supervise the male resident were not effective in preventing the abuse of the female resident. The failure to provide adequate supervision and protection resulted in a witnessed incident of nonconsensual sexual contact, constituting a failure to ensure residents' rights to be free from abuse and neglect.
Failure to Ensure Dignified and Respectful Transportation for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity by not providing appropriate transportation methods for medical appointments, as evidenced by the experiences of two cognitively intact female residents. One resident, who had a history of sepsis, pyogenic arthritis, COPD, and acute pyelonephritis, reported being transported in her wheelchair across a bumpy street to a doctor's office instead of being taken in the facility van. This method of transportation caused her significant knee pain, especially as she was scheduled to receive a knee injection at the appointment. There was no documentation in her medical record explaining why the van was not used for her transport. Another resident, with diagnoses including aftercare following joint replacement, overactive bladder, difficulty walking, anxiety disorder, and Type 2 Diabetes Mellitus, also reported being taken to a doctor's appointment in her wheelchair. She stated that the van driver told her it would be too much trouble to load her into the van for a short trip across the street. This resident expressed feeling embarrassed by being pushed in her wheelchair down the street and indicated she was not given a choice regarding her preferred method of transportation. Interviews with other residents and staff confirmed that transporting residents in wheelchairs across the street was a common practice, and that residents were not routinely asked for their preferences regarding transportation. The facility's policy required that residents be transported in a safe manner by a licensed driver, secured by seat belt in the vehicle, and assisted in and out of the vehicle by trained staff, but these procedures were not followed in the cases described.
Staff Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when a staff member, identified as HSK B, misappropriated funds from a resident with impaired cognitive function. The resident, a female with diagnoses including sepsis, mild cognitive impairment, and Type 2 Diabetes Mellitus, was admitted to the facility and had a BIMS score of 8, indicating impaired cognition. The resident enjoyed ordering food through delivery services, which involved the use of her bank card. On attempting to pay the resident's applied income, the Business Office Manager discovered insufficient funds in the resident's account due to multiple unauthorized Cash App withdrawals made to HSK B. The facility's investigation revealed that the withdrawals were made directly from the resident's bank card, with at least one transaction linked to HSK B's boyfriend, who was not employed at the facility. When confronted, HSK B denied taking the money. The incident was reported to the police, and the case was referred to the Criminal Investigation Division. The police investigation was delayed due to the need for additional documents from the resident, who was reportedly planning to move out of the country. Staff interviews confirmed that employees had received training on abuse, neglect, and misappropriation of resident property, and were aware of the protocols for reporting such incidents. The facility's policy defined misappropriation as the deliberate or wrongful use of a resident's belongings or money without consent. No other residents reported similar issues during subsequent safe surveys and grievance log reviews.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for missed or inaccurate care. Resident #42's quarterly MDS assessment did not reflect the presence of a cardiac pacemaker, despite it being a significant part of his medical history. His comprehensive care plan and active orders indicated the need for daily monitoring of his apical pulse due to the pacemaker, yet this critical information was omitted from the MDS assessment. Interviews with staff revealed that a new MDS nurse, who was still learning, completed the assessment and missed this diagnosis. Resident #84's quarterly MDS assessment failed to document her history of falls since admission. Her comprehensive care plan highlighted her high risk for falls due to limited mobility, impaired vision, and other factors. Despite a fall occurring on 06/04/2024, and her being assessed as high risk for falls, this information was not included in the MDS assessment. The omission was attributed to oversight by the MDS nurse, who acknowledged the need to review falls more thoroughly. Interviews with facility staff, including the ADM, MDS nurses, and the DON, emphasized the importance of accurate MDS assessments as they form the basis of care plans. The facility's policy and the CMS Long-Term Care Facility Resident Assessment Instrument Manual both stress the necessity for assessments to accurately reflect residents' statuses. The inaccuracies in the MDS assessments for Residents #42 and #84 were recognized as potentially leading to missed care, underscoring the critical nature of precise documentation.
Failure to Monitor Apical Pulse for Resident with Pacemaker
Penalty
Summary
The facility failed to ensure that a resident with a cardiac pacemaker received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, RN C did not perform an apical pulse check for the resident as ordered to monitor the function of his cardiac pacemaker. Despite the resident's care plan and active orders specifying the need for daily apical pulse monitoring, RN C admitted to using a machine and cuff for vital signs and was unaware of the resident's pacemaker. This oversight was confirmed during an interview where RN C acknowledged initialing off on the apical pulse check without actually performing it. The resident, who was cognitively intact and able to communicate, confirmed that only the doctor listened to his heart, not the nurses. The Director of Nursing (DON) stated that nurses were trained to take apical pulses and emphasized its importance for residents with pacemakers. However, the deficiency was evident as RN C, despite being signed off as satisfactory in cardiovascular assessment skills, did not follow the prescribed procedure. The facility's policy on permanent pacemakers and apical pulse monitoring was not adhered to, leading to a failure in providing the necessary care for the resident's condition.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA D and RN C during the care of a resident. During peri care, CNA D did not sanitize her hands between glove changes, which was observed at 9:21 a.m. This lapse in protocol was acknowledged by CNA D during an interview, where she admitted that not sanitizing her hands could lead to cross-contamination and potentially result in an infection or hospitalization for the resident. Similarly, RN C was observed performing wound care for the same resident without sanitizing her hands between glove changes. This was noted at 9:45 a.m., and RN C also acknowledged in an interview that she should have sanitized her hands to prevent cross-contamination. The Director of Nursing confirmed that both the nurse and CNA should have followed proper hand hygiene practices to prevent infections. The resident involved had a history of cerebral infarction, chronic atrial fibrillation, heart failure, and dysphasia, and was frequently incontinent of bowel and bladder.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eagle Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maverick Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 22 | 0 |
| Eagle Pass Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Whispering Springs Rehabilitation And Healthcare C | 38.6 mi | ★★★★★ | 1 | 0 |
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