Mabank Nursing Center

Penalty

No penalty information released

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

Summary

The facility failed to keep the resident environment free of accident hazards and to provide adequate supervision during several observed events involving mechanical lifts, fall mats, and unsecured items in resident areas. Resident #30, a female with dementia, severe cognitive impairment, muscle weakness, depression, bipolar disorder, and total assistance needs for transfers, was observed on 05/19/26 being transferred from her wheelchair to bed by CNA E and CNA B using a mechanical lift without locking the lift wheels when connecting or disconnecting the sling. Both CNAs acknowledged they did not lock the wheels, and RN A and the DON stated the wheels should have been locked during the transfer process. Resident #70, a female with muscle wasting and atrophy who used a wheelchair and required max assist for transfers, was observed on 05/19/26 being transferred by CNA H and CNA K without locking the wheels of the mechanical lift before lifting her. CNA K stated she did not know to lock the wheels, and CNA H stated she did not remember to lock them. RN A stated the wheels should be locked before raising the resident into the air. Resident #81, a male with epilepsy and traumatic subdural hemorrhage, had an order and care plan for bilateral landing mats while in bed, but observations on 05/18/26 showed a black fall mat folded up against the bedside dresser and later against the nightstand while he was asleep in bed. The resident stated he was supposed to use the fall mat when in bed, and CNA H stated nursing staff were responsible for putting the mat down. The facility also left unsecured items in resident areas. In the room shared by Resident #40 and Resident #58, a container labeled Micro-Kill One Germicida Alcohol Wipes was observed on the bathroom countertop on 05/18/26. Resident #40 had Angelman syndrome, severe cognitive impairment, and required total/maximum assistance with decision making; Resident #58 had severe cognitive impairment, memory problems, and required supervision and extensive assistance for decisions. Staff interviews stated the wipes should have been stored in a locked area, supply closet, medication cart, or supply room, and the DON and Administrator stated items should not be left in resident bathrooms. Resident #6, a female with chronic heart failure, major depressive disorder, cognitive communication deficit, delirium, and moderate cognitive impairment, was observed on 05/18/26 and again on 05/19/26 with bath wash left on the toilet in her bathroom. LVN F stated the bath wash should not have been left in the room because it could be misused, and the DON and Administrator stated it should not have been left out in resident bathrooms.

Penalty

No penalty information released

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

Summary

Drugs and biologicals were not consistently stored in locked, secure compartments and were not always labeled according to accepted professional principles. During observation of Resident #6’s room, a 4-ounce tube of zinc oxide was found in a caddy by the sink in the bathroom on multiple occasions. Resident #6 had diagnoses including chronic heart failure, major depressive disorder, cognitive communication deficit, and delirium due to a known physiological condition, and her MDS indicated moderate cognitive impairment and hallucinations. She stated she did not know what the medication was, and staff stated the zinc oxide should not have been left in the room and should have been stored on the treatment or medication cart. On Hall 400’s nurse medication cart, Resident #38’s Novolog insulin flex pen was observed opened and undated, Resident #8’s Lantus insulin was observed open and undated, and two bottles of Nystop wound care powder had no resident name label. LVN F stated she normally checked the cart for labeled insulin but did not do so when she began her shift, and she said all insulins should have dates when opened. The DON stated all insulins should be labeled and dated when opened and that the unlabeled Nystop should have had a pharmacy label specific to the resident. RN D was observed entering a resident’s room to administer medications while leaving the Hall 500 nurse medication cart open and unattended. RN D stated he was responsible for ensuring the cart was locked while unattended. In addition, Resident #90 had a cup of white cream sitting on the bedside nightstand, and the resident stated it had been given by the nightshift nurse for back pain. Record review showed no order for topical medication, and staff stated the resident was not supposed to have medications at the bedside. The facility’s medication storage policy stated drugs and biologicals are to be stored in locked compartments.

Penalty

No penalty information released

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

Summary

The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. During record review and interviews, the hospice binders for multiple residents were found to be incomplete or missing current hospice documentation, including physician certification of terminal illness, interdisciplinary group (IDG) meeting records, recertification forms, election forms, medication profiles, and the most recent plan of care. For one resident with dementia, muscle weakness, anxiety, and depression, the hospice binder did not contain the physician certification of terminal illness, the last two IDG meetings, or an updated recertification form. The last recertification in the binder covered an earlier certification period. The hospice RN stated that the binder should contain supporting hospice documentation and that the missing IDG meetings and recertification had not been delivered to the facility. The RN also stated that the documentation should be updated after the IDG meetings and that the binder was important for the facility to know the care and services being provided. For another resident with senile degeneration of the brain and major depressive disorder, the hospice binder contained an older IDG meeting but did not contain the current hospice IDG meeting. The hospice RN stated that an IDG meeting had occurred but was not in the binder, and the hospice regional marketing coordinator stated she was responsible for printing and delivering updated paperwork after each meeting. For a third resident with cerebrovascular disease and gastroesophageal reflux, the hospice binder was missing the updated hospice election form, certification of illness, IDG meetings, most recent medication profile, and most recent plan of care. Staff interviews reflected that the paperwork should have been in the facility binder on admission, but it had not been checked or provided as expected.

Penalty

No penalty information released

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

Summary

The facility failed to maintain infection prevention and control practices for multiple residents during observed care and room checks. Resident #52 had a gastrostomy tube, moderate cognitive impairment, and a care plan requiring enhanced barrier precautions for high-contact care because of an indwelling medical device. During an observation, LVN F administered gastrostomy tube medications and a bolus feeding without wearing any PPE, despite the EBP signage on the door. LVN F stated she believed only gloves were needed for medication and feeding administration and said she did not need a gown unless the resident had a respiratory infection. The facility also failed to keep resident toothbrushes stored and labeled separately in shared bathrooms. Resident #4, Resident #87, Resident #91, and Resident #12 all had significant cognitive impairment and required staff assistance with ADLs. Observations showed toothbrushes for these residents lying together in bathrooms without containers and without labels. In one bathroom, two toothbrushes were lying together in a caddy beside the sink; in another, two toothbrushes were lying together with no container and unlabeled; and later one toothbrush was on the sink and another was in a caddy without a container and unlabeled. Staff interviews confirmed that toothbrushes should have been stored in separate labeled containers, and the DON and Administrator stated the facility had specific storage containers for resident personal items. The facility further failed to ensure proper incontinent care and hand hygiene during direct resident care. Resident #82 was totally incontinent of bladder and required staff assistance with toileting and perineal care. During observation, CNA E wiped the resident’s perineal area using both front-to-back and back-to-front motion, did not change gloves or perform hand hygiene when moving from dirty to clean areas, and used the same gloves while handling a clean brief and linen. After leaving Resident #82’s room, CNA E entered Resident #44’s room without washing her hands and provided care before washing her hands after leaving that room. CNA E acknowledged she did not perform hand hygiene or change gloves appropriately, and the DON and Administrator stated they expected staff to wipe front to back, change gloves between dirty and clean tasks, and perform hand hygiene before leaving one room and entering another.

Penalty

No penalty information released

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

Summary

The facility failed to treat a resident with respect and dignity when MA L called Resident #75 a feeder while assisting her to eat on 05/18/2026. Resident #75 was a female admitted with senile degeneration of the brain and major depressive disorder. Her quarterly MDS indicated she usually made herself understood, only sometimes understood others, had a BIMS score of 02 showing severely impaired cognition, and was coded as needing helper assistance only prior to or following eating, with the resident completing the activity once the meal was placed before her. Her care plan identified an ADL self-care performance deficit related to muscle weakness with an intervention for supervision/set-up assistance with eating, and her meal ticket listed adaptive equipment of a 2-handed cup. During an interview on 05/18/2026, MA L stated in the hall while CNA H was passing trays that Resident #75 was a feeder, indicating that she required assistance with meals from CNA H. On 05/19/2026, CNA H stated that Resident #75 required assistance with meals and that it was important to assist her with meals to prevent weight loss. MA L later stated that she accidentally called Resident #75 a feeder and acknowledged that it was undignifying. RN A, the DON, and the Administrator each stated that staff were expected to address residents with dignity and respect, and the Administrator stated it was inappropriate to call Resident #75 a feeder at all times. The facility policy stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity.

Penalty

No penalty information released

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

Summary

The facility failed to ensure Resident #61 had his call button within reach while he was in bed on 05/18/26 and 05/19/26. Resident #61 was an [AGE]-year-old male admitted with diagnoses including dementia, type 2 diabetes, depression, and high blood pressure. His admission MDS dated 03/20/26 showed a BIMS score of 11, indicating moderate cognitive impairment, and he required supervision with toileting, bed mobility, dressing, transfers, and personal hygiene, with set up for eating. He was also occasionally incontinent of bladder. Resident #61’s care plan, revised 04/28/26, identified him as at risk for falls related to gait and balance problems and being unaware of safety needs, with interventions directing staff to ensure the call light was within reach and to encourage him to use it for assistance as needed. During observations on 05/18/26 and 05/19/26, he was lying in bed and his call light was on the other side of his roommate’s bed. When asked what he would do if he needed help, he looked for the call light, said he did not see it, and stated he might have to yell for help. A CNA confirmed the call light was out of reach and stated all residents’ call lights should always be in reach.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that advance directive paperwork was completed correctly for 2 of 22 residents reviewed. Resident #40, a male with Angelman syndrome who rarely or never made himself understood and rarely or never understood others, had an active DNR order and a care plan noting that the resident/family had chosen DO NOT RESUSCITATE. However, the resident’s OOH-DNR form was missing the legal guardian’s signature, printed name, and the date the document was signed by the legal guardian and the two witnesses. Resident #64, a female with spondylosis and a BIMS score of 10 indicating moderately impaired cognition, also had an active DNR order and a care plan reflecting that the resident/family had elected DNR status. Her OOH-DNR form was missing the physician’s signature. During interview, the Social Worker stated she was responsible for completing DNRs and acknowledged the missing information on both residents’ forms, describing it as human error. The DON and Administrator stated they expected DNRs to be completed accurately and that the Administrator was responsible for monitoring and overseeing them, but the system in place only monitored whether a resident had a DNR, whether it was uploaded, whether the order was correct, and whether it was care planned, not whether the actual document was complete.

Penalty

No penalty information released

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

Summary

The facility failed to implement its written abuse prohibition policy when it did not report a resident-to-resident altercation to the state agency. The policy stated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source were to be promptly reported and thoroughly investigated, and that alleged abuse involving abuse was to be reported immediately, but not later than 2 hours. The policy also stated that in resident-to-resident suspected abuse, the parties were to remain separated until the investigation was completed. Resident #56 was a female with diagnoses including dementia, anxiety, depression, and high blood sugars. Her quarterly MDS reflected a BIMS score of 03, indicating severely impaired cognition, and her care plan identified a potential for verbal aggression related to dementia, ineffective coping skills, and poor impulse control. Resident #49 was also a female with diagnoses including dementia, high blood sugars, and depression. Her admission MDS also reflected a BIMS score of 03 and severely impaired cognition, and her care plan likewise identified a potential for verbal aggression related to dementia, ineffective coping skills, and poor impulse control. The incident report documented that the two residents were arguing in the dining room, holding each other's arms, yelling, and becoming aggressive. The DON's account stated that Resident #56 moved close to Resident #49's wheelchair, slapped at Resident #49's upper arm, and Resident #49 responded with a closed fist waving it at Resident #56. Staff intervened and separated the residents. Other staff interviews described loud yelling, cursing, swinging at each other, and one resident holding the other resident's sweater. The DON and Administrator later determined the event did not need to be reported to HHSC because they believed it was only verbal and not willful, despite the policy requiring reporting of alleged abuse and the documentation of physical contact during the altercation.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or injuries of unknown source were reported immediately, and no later than 2 hours after the allegation was made, for two residents involved in a resident-to-resident altercation. The incident involved a verbal and physical confrontation between two female residents with dementia and severely impaired cognition, both of whom had care plans noting a potential for verbal aggression related to dementia, ineffective coping skills, and poor impulse control. Record review showed that one resident was heard yelling in the dining room and was found arguing with the other resident while they were holding each other's arms. Another incident report documented that one resident moved close to the other resident's wheelchair, tapped her own wheelchair, and then slapped at the other resident's upper arm. The second resident responded with a closed fist and waved it at the first resident. Staff intervened, separated the residents, and both were described as verbally aggressive, verbally threatening each other, and grabbing at each other's hands. One resident said the other had stolen her sweater from the laundry, and the sweater was later removed and given to staff. Interviews with staff showed that the DON was notified at the time of the altercation, and the Administrator later signed the incident report. The DON stated she did not believe the event needed to be reported because it was only verbal and both residents had cognitive impairment. The Administrator said she did not recall the altercation, did not believe it was willful, and did not know when reporting was required without referring to her flow chart. The facility policy stated that alleged abuse, neglect, exploitation, mistreatment, and injuries of unknown source must be reported immediately, and no later than 2 hours if the alleged violation involves abuse.

Penalty

No penalty information released

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

Summary

The facility failed to ensure assessments were coordinated with the PASRR program to the maximum extent practicable and failed to incorporate PASRR recommendations into assessment, care planning, and transitions of care for one resident reviewed for PASRR. The deficiency involved Resident #5, a female admitted with diagnoses including major depressive disorder, bipolar disorder, and anxiety. Her annual MDS assessment marked that she was not currently considered by the state level II PASRR process to have serious mental illness or intellectual disability, and the Level II PASRR conditions section was not checked for serious mental illness, intellectual disability, or other related conditions. Her care plan addressed antidepressant and antianxiety medications with interventions to give medications as ordered and monitor/document side effects and effectiveness. Record review showed a PASRR Level 1 Screening form dated 06/01/22 stated Resident #5 had no evidence or indicator of dementia or a mental illness. A later PASRR Level 1 Screening form dated 05/19/26 also stated she had no evidence or indicator of dementia or a mental illness. The record also reflected a Mental Illness/Dementia Resident Review Form 1012 submitted on 05/19/26. During interview, Resident #5 stated she always had a history of mental illness. The MDS Coordinator stated the previous MDS Coordinator was responsible for ensuring the PASRR Level 1 was completed accurately and that a Form 1012 should have been completed to correct the inaccurate PASRR Level 1 so a new screening could be submitted if needed. The Clinical Reimbursement Specialist stated that if a Level 1 was incorrect, a Form 1012 should be completed so the resident could be reevaluated for services, and that the MDS Coordinator was responsible for ensuring this was done for Resident #5. The DON stated she expected the paperwork that goes along with PASARR to be filled out correctly and that she was responsible for monitoring and overseeing PASARR by attending meetings and reviewing paperwork to ensure it was submitted into SIMPLE and rehabilitation appropriately. The Administrator also stated she expected Form 1012 to be completed and an updated PASARR Level 1 submitted, and that the MDS Coordinator was responsible for ensuring the form was completed when the first PASARR Level 1 was inaccurate.

Penalty

No penalty information released

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

Summary

Resident #10, a male admitted with diffuse traumatic brain injury and severe cognitive impairment, had an order for oxygen via nasal cannula at 2-3 L and for the nasal cannula, oxygen tubing, water bottle, and concentrator filter to be changed every Wednesday night shift. The resident’s MDS indicated he was rarely understood by others, rarely able to understand others, and had a BIMS score of 00. During observation, his nasal cannula tubing and water container were dated 05/07/2026, and the water container was empty while oxygen was in use at 3 L via nasal cannula. During interviews, CNA H stated nursing was responsible for changing oxygen supplies and checking that the tubing and water container were in date, but she was unaware of when the tubing was to be changed and did not know the water canister was empty. RN A stated she changed the oxygen tubing on 05/18/2026 after noticing it needed to be changed and was unsure when the supplies were scheduled to be changed. The DON and Administrator stated nursing was responsible for ensuring oxygen supplies were stored and changed properly and that the tubing and water canister were expected to be changed per orders and policy. The facility’s oxygen administration policy stated oxygen cannula and tubing would be changed every 7-10 days or if visibly soiled and the prefilled humidifier would be changed when the water level became low.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents with trauma histories received trauma-informed and culturally competent care. For one resident, the record showed admission diagnoses including high blood pressure, cognitive impairment following cerebrovascular disease, and GERD. Her admission MDS indicated severely impaired cognition, and her baseline care plan did not include any past trauma or triggers. The trauma-informed care assessment stated the social worker was unable to determine whether she had experienced any traumatic event, and the social history did not identify trauma or triggers even though it was completed with the resident and a family member. During interviews, staff stated they were aware that this resident had prior trauma related to a group of men breaking into her house and that being confined and men triggered her behaviors. The hospice RN said floor staff had been notified on admission that she had been attacked in her home by a group of men and that men triggered her. The social worker stated a family member had reported childhood teasing and the prior attack by a group of men, and said this information should have been included in the assessment record and care plan, but it was not provided. The DON and Administrator stated their expectation was that the social worker obtain the information, document trauma and triggers, and include them in the baseline care plan. For a second resident, the record showed diagnoses including PTSD, anxiety, and COPD, and the MDS indicated intact cognition and a diagnosis of PTSD. The medical record did not contain a trauma assessment or trauma screen. The comprehensive care plan addressed behavioral problems related to mental illness and PTSD, but the trauma assessment itself was missing. The DON stated she could not find the trauma assessment and believed it had not been done. The social worker stated she was responsible for trauma assessments, was aware of reported sexual trauma prior to admission, and said the facility had not been doing trauma assessments when she was first hired. She also stated that trauma assessments were being done for new admissions and certain readmissions, and that the purpose was to identify trauma and triggers so a plan of care could be developed to reduce recurrence.

Penalty

No penalty information released

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

Summary

The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services because one dietary aide did not maintain a current Food Handler Certificate. Record review showed Dietary Aide C was hired on 10/01/23 and had a Texas Food Handler Certificate issued on 02/14/24 with an expiration date of 02/13/26. During interview, the Dietary Manager stated the certificate should be renewed every 2 years and acknowledged she had not paid attention to when the certificate would expire. She also stated that she and the Business Office Manager were responsible for ensuring dietary staff had their food handler certificates. During interview, Dietary Aide C said she did not realize her certificate had expired and said the Dietary Manager told her the day before that it had expired. She stated she knew the certificate was required but did not see the risk in not updating it because she knew what to do. The Dietary Manager, DON, and Administrator all acknowledged responsibility for maintaining current certificates, and the Administrator stated she was not aware the certificate had expired. Record review of the policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, stated that all employees who handle, prepare, or serve food will be trained in safe food handling and preventing foodborne illness and must demonstrate knowledge and competency before working with food or serving food to residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide respiratory care consistent with professional standards for three residents, leading to deficiencies in oxygen administration and nebulizer mask storage. Resident #3, diagnosed with chronic obstructive pulmonary disease, was observed with oxygen set at 1 liter per minute (lpm) instead of the prescribed 3 lpm. Additionally, her nebulizer mask was improperly stored, being left unbagged on a mini fridge and later found on the floor. These observations were made despite the resident's care plan indicating the need for oxygen therapy and proper storage of respiratory equipment. Resident #66, who has Alzheimer's disease and a history of a femur fracture, was found with her oxygen set between 3-4 lpm, contrary to the physician's order of 2 lpm. The Licensed Vocational Nurse (LVN) responsible for checking the oxygen settings admitted to not knowing the correct settings and acknowledged the importance of adhering to the physician's orders to prevent respiratory distress. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the nurses should ensure oxygen is set according to orders and that nebulizer masks should be bagged to prevent contamination. Resident #19, with diagnoses including dementia and COPD, was observed with her oxygen set at 2 lpm instead of the ordered 3 lpm. Her nebulizer mask was also found unbagged on the nightstand, and her oxygen tubing was on the floor. The LVN and DON acknowledged the importance of following physician orders and proper storage of respiratory equipment to prevent infection and ensure adequate oxygenation. The facility's policies on oxygen administration and nebulizer use emphasize the need for correct oxygen settings and proper storage of equipment, which were not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in implementing contact precautions for residents diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Resident #39, who had a wound culture indicating MRSA, was not placed on contact precautions. The Wound Care Nurse and the Director of Nursing (DON) did not recognize the need for contact precautions, despite the presence of MRSA, and relied on the wound care doctor and primary care team for guidance. This oversight was acknowledged by the DON, who admitted to not interpreting the wound culture results correctly. Resident #41, who was on contact isolation precautions due to MRSA in the urine, experienced multiple instances where staff failed to adhere to the required personal protective equipment (PPE) protocols. CNA F, CNA B, and Housekeeper E entered Resident #41's room without wearing the necessary gown and gloves, despite the presence of a contact isolation sign on the door. These staff members either misunderstood the requirements or neglected to follow the established protocols, increasing the risk of infection spread. Interviews with staff, including the DON and the Regional Vice President (RVP), highlighted a lack of adherence to infection control policies and a misunderstanding of the necessary precautions. The facility's policies on infection prevention and control, as well as isolation precautions, were not effectively implemented, leading to potential cross-contamination and the spread of infection among residents and staff.

Penalty

No penalty information released

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

Summary

The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the actions of a Laundry Aide who entered the rooms of two residents without knocking or introducing herself. This incident involved a female resident with unspecified intellectual disabilities and severely impaired cognition, and another female resident with severe unspecified dementia and behavioral disturbances, both of whom were sleeping at the time. The Laundry Aide admitted to not following protocol because the residents were asleep, despite acknowledging the importance of knocking and introducing herself to avoid making residents feel uncomfortable or invaded. Interviews with the Housekeeping Supervisor, the Director of Nursing (DON), and the Regional President confirmed that the facility's policy required staff to knock and introduce themselves when entering residents' rooms, emphasizing the importance of respecting residents' privacy and treating them with dignity. The facility's policy on Resident Rights, revised in October 2022, mandates that employees treat all residents with kindness, respect, and dignity. The failure to adhere to this policy was observed and documented by the surveyor, highlighting a deficiency in maintaining the residents' quality of life and dignity.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's call button was within reach, which is a reasonable accommodation of the resident's needs and preferences. This deficiency was observed when Resident #37 was found sitting in a standard chair with the call light on the floor on the other side of the bed, making it inaccessible. The resident, who is severely cognitively impaired with a BIMS score of 02, requires assistance with activities of daily living and is occasionally incontinent. Despite these needs, the call light was not placed within reach, and the resident was unable to answer questions about its use. Interviews with staff revealed that the CNA responsible for Resident #37 did not place the call light within reach, citing concerns that the resident might pull it out of the wall or throw it, potentially causing a fall. The CNA admitted to not placing the call light next to the resident since the start of her shift. The LVN and DON both emphasized the importance of having call lights within reach for all residents, regardless of cognitive deficits, as a means of communication for assistance. The facility's policy mandates that call lights be easily reachable by residents, yet this was not adhered to in the case of Resident #37.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, identified as Resident #19, who was observed to have a persistent urine odor in her room and on her person. Resident #19, an elderly female with severe cognitive impairment due to dementia, was incontinent of bowel and bladder and required assistance with daily living activities. Despite the staff's efforts to maintain cleanliness, the urine odor was noted during multiple observations and interviews, indicating a deficiency in maintaining a homelike environment. Interviews with staff and the resident's roommate confirmed the presence of the urine odor, which was a source of discomfort for the roommate. The staff, including a CNA and an LVN, acknowledged the odor issue and mentioned attempts to manage it with a diffuser, which was found empty during an inspection. The Director of Nursing and the Regional President were aware of the odor problem and expressed a commitment to maintaining an odor-free environment, but the issue persisted, affecting the quality of life for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical and care needs. For one resident, the facility did not create a care plan specific to her non-pressure wounds, which included wounds on her right foot, right shin, and left posterior ankle. Despite having detailed wound care orders and evaluations, the care plan did not reflect these treatments or the specific locations of the wounds. Interviews with the Director of Nursing (DON) and the Wound Care Nurse revealed that the care plan should have been person-centered and included all treatments and services the resident received. Another resident's care plan was not updated to reflect a change in code status from Full Code to Do Not Resuscitate (DNR). Although the DNR status was documented in the resident's physician orders and electronic medical records, the care plan still indicated a Full Code status, which could lead to inappropriate life-saving measures being administered. Interviews with the Social Worker, DON, and MDS Coordinator highlighted a lack of communication and responsibility in updating the care plan to reflect the resident's current wishes. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to update and individualize care plans for these residents indicates a breakdown in the facility's processes for ensuring accurate and current care plans. This deficiency could result in residents not receiving the appropriate care and services tailored to their specific health needs and preferences.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. The resident, who was diagnosed with quadriplegia, traumatic brain injury, and muscle wasting, was dependent on staff for all activities of daily living and had functional limitations in range of motion in both upper and lower extremities. The resident's care plan included the use of medical devices known as 'carrots' to treat hand contractures, but observations revealed that these devices were not consistently placed in the resident's hands as required. During multiple observations, the resident was found without the carrots in his hands, and staff interviews revealed a lack of consistent implementation of the care plan. A Licensed Vocational Nurse (LVN) admitted to signing off on the task without completing it and mentioned that the task could be delegated to Certified Nursing Assistants (CNAs). However, a CNA reported difficulty in placing the carrots due to the resident's contracted hands and usually deferred the task to the nurse or therapy staff. The Director of Nursing (DON) confirmed that CNAs were trained to place the carrots and emphasized the importance of doing so to prevent further contractures and wounds. Despite this, the facility's policy for contracture management was not provided upon request.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. Specifically, the resident's foley catheter drainage bag was observed on the floor, which is against the facility's policy and poses a risk for contamination and infection. The resident, a male with neuromuscular dysfunction of the bladder and benign prostatic hyperplasia, required partial assistance with toileting and had an order for regular catheter bag changes. Despite these measures, the catheter bag was not maintained properly, as observed during a facility visit. Interviews with staff, including an LVN, CNA, DON, ADON, and RVP, confirmed that the catheter bag should not be placed on the floor due to the risk of bacterial contamination and infection. The staff acknowledged their responsibility in ensuring the catheter bag was kept off the floor, yet the deficiency was noted during the survey. The facility's policy on emptying urinary drainage bags also emphasized keeping the bag and tubing off the floor to prevent contamination, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma. The resident, a female with severe cognitive impairment and diagnoses of anxiety disorder and dementia, did not have her history of trauma documented in her care plan. This omission was identified during a review of the resident's records, which showed that a social worker had noted the history of trauma and abuse by a family member. However, this critical information was not included in the care plan, which is essential for guiding staff in providing appropriate care and preventing potential re-traumatization. Interviews with facility staff revealed a lack of clarity regarding responsibility for updating the care plan with the resident's trauma history. The social worker acknowledged the importance of including this information but was unsure who should add it to the care plan. The Director of Nursing (DON) indicated that the social worker should inform the nursing staff to ensure the care plan is updated. The Regional President emphasized the necessity of having complete and individualized care plans. The facility's policy on trauma-informed care also underscored the need for care plans to include individualized interventions and potential triggers, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all drugs were only accessible by authorized personnel, as evidenced by an incident involving a resident's medication being left unattended. On March 10, 2025, a medication named Breo Ellipta, prescribed for a resident with chronic obstructive pulmonary disease (COPD), was observed on the resident's bedside table with 18 puffs remaining. The resident, who was cognitively intact and required assistance with daily activities, had a physician's order for the medication to be administered once daily. However, the medication was left unattended by the nurse responsible for its administration, who admitted to being called away and forgetting to remove the medication from the room. Interviews with facility staff, including a CNA, LVN, and the Director of Nursing (DON), confirmed that medications should not be left at the bedside unattended. The DON emphasized that no residents in the facility were permitted to self-medicate, and leaving medications unattended could result in missed doses or unauthorized access by other residents. The facility's policy on medication storage, revised in April 2019, mandates that all drugs and biologicals be stored in locked compartments, highlighting the deviation from established procedures in this incident.

Penalty

No penalty information released

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

Summary

The facility failed to accommodate a resident's food preferences, specifically the preference for bacon over sausage, which was not honored. The resident, who was cognitively intact and required supervision with eating, had expressed her dislike for sausage and preference for bacon multiple times to the nursing staff. Despite this, she continued to receive sausage for breakfast on multiple occasions. The resident's care plan and diet history did not reflect her food preferences, although her meal tickets did note her dislike for sausage and preference for bacon. Interviews with the dietary manager and staff revealed that the resident's food preferences were known and documented on her meal tickets. However, there was a lapse in ensuring these preferences were consistently honored, as evidenced by the resident receiving sausage instead of bacon. The dietary manager acknowledged the importance of adhering to residents' food preferences to ensure they eat and maintain their caloric intake. The facility's policy required the documentation of food preferences upon admission and as needed, but this was not effectively implemented in this case.

Penalty

Inspection fine: $31,234

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

Summary

The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for one resident who experienced a deterioration in health, including head leaning heavily to the left, heavy incontinence, confusion, weakness, and the need for a two-person assist. The facility did not notify the physician of these changes on the specified date. Additionally, the facility failed to notify the physician of the resident's respiratory distress on another date. The resident's vital signs indicated respiratory distress, with an oxygen saturation of 88% and respirations at 30 breaths per minute. Despite these critical changes, the physician was not informed in a timely manner, which could have allowed for an assessment and a plan of care to be decided upon. The resident was later admitted to the hospital with diagnoses including sepsis, pneumonia, COVID-19, influenza, and dehydration. The cause of death was determined to be respiratory failure due to COVID pneumonia. Interviews with facility staff revealed that the nurse practitioner was out of the country during the time of the resident's condition changes, and the physician was not notified of the cumulative changes in the resident's condition.

Removal Plan

• Suspending and then terminating RN A
• In-servicing staff regarding notification of changes

Penalty

Inspection fine: $31,234

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

Summary

The facility failed to provide appropriate treatment and care for a resident, leading to a deficiency in quality of care. The resident, who was severely cognitively impaired and had a history of Alzheimer's, muscle weakness, and anxiety, exhibited significant changes in condition, including head leaning, confusion, and weakness, which were not recognized as a change of condition by the facility on the specified date. Additionally, the facility did not ensure that fluid intake was encouraged or increased after lab results indicated the resident was positive for a urinary tract infection (UTI). The facility also failed to follow up promptly on the resident's lab results, which were positive for a UTI, resulting in a two-day delay in addressing the issue. Furthermore, the facility did not provide oxygen therapy when the resident was in respiratory distress, as evidenced by low oxygen saturation levels and increased respiration rates. The resident's condition deteriorated, leading to hospitalization with diagnoses including sepsis, pneumonia, COVID-19, and dehydration. Interviews with staff revealed a lack of communication and timely notification to the physician regarding the resident's change in condition and lab results. The physician stated that they were not notified of the resident's respiratory distress or lab results, which delayed the necessary medical intervention. The facility's policies on change in condition and lab result communication were not followed, contributing to the deficiency in care provided to the resident.

Removal Plan

• Terminating RN A
• In-servicing staff regarding notification of changes, hydration/keep encouraging hydration/fluids, and indications for oxygen