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 Navasota Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to consistently complete and document weekly skin assessments for three at-risk residents with impaired mobility, cognitive impairment, incontinence, and protein calorie malnutrition. One resident had a new heel dressing and pain with movement, another had a new red foot area and sacral skin sheering, and staff confirmed the required skin checks were not consistently done or charted as expected by policy.
Failure to Maintain Privacy During Personal Care: A resident with dementia, ESRD, and moderate cognitive impairment was observed receiving personal care with the room door open, leaving her completely naked and visible from the hallway. CNA and HA interviews confirmed staff knew the door should have been closed for privacy, and the ADM stated staff were expected to provide privacy during care by at least pulling the curtain and closing the door.
Nonfunctioning Resident Call Light System: A resident with Alzheimer’s disease and significant cognitive impairment was observed in bed with a call button on the tray table that was not attached to anything. When the resident pressed it, the device did not alert the nurses station. A CNA/med aide and MTS confirmed the call button was not working, and the ADM stated staff had not been given routine guidance for checking call lights unless a resident reported a problem.
Failure to Post Daily Nurse Staffing and Census Information: Surveyors found that required daily staffing and census postings were not current and were missing for several days. A posting outside the ADM’s office showed outdated information on one day and a later-dated posting on another, while the ADM, DON, and ADON stated the facility lacked a posting policy, the ADON had only recently been assigned the task, and the information was posted late after the omission was noticed.
A resident with Alzheimer’s disease, gait abnormalities, bipolar disorder with psychotic features, generalized muscle weakness, and severely impaired decision-making repeatedly lay on a mattress placed on the floor beside the bed and crawled off the mattress toward a roommate’s bed, as documented in multiple nurse notes. Despite these documented behaviors and the use of the floor mattress, the comprehensive care plan was not updated to include this intervention or the resident’s crawling behavior, so it did not appear on the CNA Kardex. Interviews with the MDS coordinator, DON, CNA, LVNs, Administrator, and Nurse Consultant confirmed that such behaviors and interventions were expected to be care planned, that the Kardex information is derived from the care plan, and that there were inconsistencies and gaps in staff training and documentation practices related to care plan revisions.
The facility did not provide or document group, individual, or independent activities for all residents over a two-month period, as confirmed by record review, resident interviews, and staff admission. Several residents with mental health diagnoses reported boredom and lack of engagement during this time, and the Activity Director acknowledged the lapse in both activity provision and documentation.
Three residents with mental health diagnoses and behavioral challenges did not receive adequate psychiatric services, as psychiatric visits focused mainly on medication management and lacked individualized counseling or assessment of emotional well-being. Residents reported that their emotional needs and recent behavioral incidents were not addressed during psychiatric visits, and care plans were not fully implemented to meet their psychosocial needs.
Two residents with intact cognition and behavioral health diagnoses were involved in escalating arguments over hygiene, culminating in one physically assaulting the other in the therapy room. Staff present attempted verbal de-escalation but did not physically intervene, resulting in the assaulted resident sustaining a nose injury. The staff were unaware of prior conflicts and did not implement effective interventions to prevent the abuse.
Staff failed to keep a shower room door closed and locked, leaving hazardous chemicals accessible and unsupervised. Interviews with a CNA, DON, and Administrator confirmed that the expectation was for the door to remain locked, but the door was left open and staff could not recall the last in-service on this policy. The facility also lacked a formal protocol for accidents and hazards, and was unable to provide all required Safety Data Sheets for chemicals found in the shower room.
A resident with severe cognitive impairment and cervical fractures developed unstageable pressure ulcers under a C-collar due to staff failing to remove the collar for regular skin assessments, improper application and maintenance of the collar (including excessive taping and soiling), and lack of appropriate care planning and documentation. Staff interviews and record reviews confirmed that required skin checks and interventions were not performed, leading to the discovery of severe wounds and an Immediate Jeopardy finding.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A medication cart was found unlocked and unattended near a nurse's station, with medications and biologicals accessible. An RN admitted to leaving the cart unsecured while assisting a resident, and both the DON and Administrator confirmed that staff had been in-serviced on the requirement to keep carts locked when not in use. Facility policy requires secure storage of all medications, accessible only to authorized personnel.
The facility did not ensure that information about the grievance process was accessible to residents, with postings placed out of reach and residents reporting they were unaware of how to file grievances or where to find forms. Interviews confirmed that most residents had not received information about voicing concerns, and the facility's policy requiring prominent postings and access to grievance forms was not followed.
Three residents who were unable to perform ADLs did not receive necessary assistance with hygiene, including regular bathing, nail care, and clothing changes. One resident had long, dirty fingernails and was not provided with proper nail care, another did not consistently receive scheduled baths or nail trimming, and a third wore the same stained clothing for days and missed multiple scheduled baths. Staff interviews revealed gaps in training and awareness regarding their responsibilities for providing personal hygiene care.
A resident with severe dementia and hypertension did not receive daily vital sign monitoring as ordered by a physician and required by a QAPI initiative. Over a 68-day period, vital signs were not recorded for 58 days, despite the resident being on antihypertensive medications. Staff interviews revealed confusion about responsibility for obtaining vital signs, and system setup issues prevented proper tracking. Nursing and administrative staff acknowledged the failure to follow physician orders for daily monitoring.
A Dietary Aide was observed preparing dessert and washing dishes in the kitchen without a hair restraint, despite being aware of the requirement and having received training. The Dietary Manager and Administrator confirmed that all dietary staff were expected to wear hair nets, and facility policy mandated their use to maintain sanitary food preparation.
A loose Tramadol pill, a controlled substance, was discovered unsecured in an RN medication cart. Nursing staff confirmed the medication was not properly secured, administered, or disposed of per facility policy. Audits showed the narcotic counts for two residents prescribed Tramadol were correct, and leadership indicated the pill may have fallen out during preparation. Facility policy requires strict handling of controlled substances, and the incident indicated a failure to ensure proper medication security and administration.
A resident with Parkinson's disease, malnutrition, and no natural teeth experienced pain when eating and had not seen a dentist during her stay, despite a care plan and physician order for dental consult. Staff interviews revealed confusion over referral responsibilities, and records showed no dental consult was arranged. The facility's policy required coordination between nursing and social services for dental care, but this was not followed, resulting in unmet oral health needs.
A nurse failed to wear gloves while opening oral medication capsules for a resident with severe dementia and other health conditions, despite facility policy and infection control standards requiring glove use. Multiple staff confirmed that gloves should have been used to prevent cross contamination during medication administration.
The facility did not ensure that survey results and plans of correction were accessible and visible to residents, their legal representatives, or visitors. The survey book was hidden behind a plant stand and only contained one survey report, while several residents reported not knowing how to access the information. The ADM was unaware of the full requirements for maintaining and updating the survey book.
The facility did not maintain sufficient numbers of nurse aides and licensed nurses on several shifts, resulting in missed care such as delayed call light response and incomplete assistance with activities of daily living. Residents and staff reported chronic understaffing, frequent call-ins, and high turnover due to low pay and overwork. Facility records and interviews confirmed that posted staffing requirements were not met, and staff from other departments had to assist with resident care to compensate for the shortages.
The facility failed to ensure that call lights were within reach for three residents, affecting their ability to request assistance. A resident with Alzheimer's had her call light behind her bed, another with hemiplegia found his call light inaccessible, and a third with dementia had her call light on the floor. Staff interviews confirmed the expectation for call lights to be within reach, but this was not consistently maintained.
A facility failed to include psych services in a resident's care plan, despite the resident receiving these services as per physician orders. The resident, with dementia and major depressive disorder, was seen by psych services, but this was not reflected in the care plan. Interviews with the DON and RCN confirmed the oversight, citing the absence of an MDS coordinator and the responsibility of the IDT to ensure accurate care plans.
A resident with severe cognitive impairment experienced multiple falls, but the facility failed to update the care plan to reflect these incidents. Interviews with the DON and RCN confirmed that the care plan should have been revised to ensure appropriate care. The facility's policy requires care plans to be updated based on changing needs, which was not followed in this case.
The facility failed to post daily nurse staffing information for seven consecutive days, as the new DON was unaware of this requirement and the facility lacked a policy. The administrator, who usually posted the information, was out sick, leading to the oversight. The RCN confirmed the posting responsibility was not communicated, and the weekend supervisor also did not post the information.
A resident with a history of stroke and diabetes experienced severe pain and swelling in her left arm, but the facility failed to notify her physician immediately. Despite the resident's complaints and visible symptoms, the physician was only informed during routine rounds, leading to a delayed diagnosis of a ruptured bicep tendon. The lack of timely communication and adherence to notification policies was acknowledged by the facility's DON.
A resident with PTSD was placed in a shared room, contrary to their care plan, which specified the need for a private room to prevent PTSD triggers. Facility staff, including an LVN, MDS Coordinator, and DON, were unaware or did not adhere to the care plan, leading to a deficiency in trauma-informed care. The facility's policy on trauma-informed care was not effectively implemented, placing the resident at risk for psychological distress.
A resident with severe cognitive impairment and dependent on staff for all ADLs was left in the same position in a Geri-chair for over six hours without being turned or provided incontinent care, leading to the development of two DTIs. The facility failed to follow its own care plan and policies for pressure injury prevention, resulting in skin breakdown.
The facility failed to provide a private space for resident council meetings, holding them in an open dining area without doors, compromising residents' ability to voice grievances confidentially. Residents expressed discomfort with the lack of privacy, and the facility could not provide Resident Council minutes or policy when requested.
The facility failed to provide necessary assistance for ADLs, including repositioning and incontinent care, for two residents, and did not maintain proper nail hygiene for three residents. Observations revealed saturated briefs and blackish substances under fingernails, indicating a lack of care. Staff interviews highlighted confusion over responsibilities and a failure to seek help, placing residents at risk for health issues.
A facility failed to provide resident-centered activities for four residents, leading to a lack of engagement in both one-on-one and group activities. Residents with various diagnoses, including dementia, multiple sclerosis, and sensory impairments, were observed spending significant time in their rooms with minimal stimulation, such as television. Staff interviews confirmed the absence of appropriate activities, and the facility's administrator acknowledged the deficiency.
The facility failed to properly prepare pureed food, specifically meatloaf, by using water instead of broth or thickener, contrary to the facility's recipes. Staff did not have recipes available during preparation, and interviews revealed a lack of understanding of the negative outcomes of using water, which can dilute nutritional content. The Administrator confirmed that staff were trained and recipes were available, but they were not being followed, leading to the deficiency.
The facility failed to label and date food items in storage and did not maintain proper food temperatures before serving. Observations revealed unlabeled milk, juices, dough, and sausage patties, and improper temperatures for pureed meatloaf and peas. Staff interviews confirmed awareness of the risks associated with these deficiencies.
A resident with a history of behavioral issues was left without a meal for 20 minutes while his tablemate ate, leading to feelings of frustration and anger. The delay was due to a lack of communication between nursing and dietary staff about the resident's dining location, violating the facility's dining room etiquette policy.
The facility failed to ensure call lights were within reach for two residents, leading to potential risks of falls and unmet needs. One resident with essential tremor and dementia could not reach his call light, while another with lymphedema and depression found hers behind her recliner. Staff interviews confirmed the responsibility to ensure call light accessibility, but training dates were not recalled, and the facility's policy was not provided.
A facility failed to include a resident's indwelling urinary catheter in their care plan, incorrectly noting bladder incontinence instead. The resident, with severe cognitive impairment and multiple diagnoses, was observed with the catheter drainage bag on the floor. The DON acknowledged the oversight, noting the lack of a dedicated person for care plans.
The facility failed to provide necessary interventions for two residents with hand contractures, leading to a risk of decreased mobility. One resident was observed without prescribed splints and had untrimmed nails, while another lacked consistent use of a therapy carrot. Staff cited short staffing as a reason for not implementing care plans, and the DON acknowledged the need for regular monitoring.
A resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter drainage bag placed on the floor, increasing the risk of UTIs. The facility's care plan did not address this issue or include the use of a catheter secure device. Staff interviews confirmed the lack of consistent monitoring and intervention, and the facility's policy did not cover the use of secure devices.
A resident with dementia and an indwelling urinary catheter exhibited behaviors such as placing the catheter bag on the floor and attempting to hit staff with it. The facility failed to develop a comprehensive care plan addressing these behaviors, leading to potential risks of urinary tract infections and traumatic catheter removal. Observations and interviews revealed a lack of staff awareness and documentation regarding interventions for the resident's behaviors.
An LVN failed to sanitize a common glucometer between blood sugar checks for two residents, potentially leading to contamination and disease spread. One resident was cognitively intact with Diabetes Mellitus Type II and a history of sepsis, while the other had severe cognitive impairment and Diabetes Mellitus Type II. The facility's infection control policy requires cleaning of equipment to prevent disease transmission, which was not followed.
Missed Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure weekly skin assessments were consistently completed and documented for three residents who were at risk for skin breakdown. Resident #1 had diagnoses including Alzheimer’s disease, protein calorie malnutrition, anemia, depression, insomnia, and cerebral infarction, and required maximum assistance with rolling, toileting, dressing, and personal hygiene. Resident #1’s care plan identified risk for malnutrition and pressure ulcer development related to decreased mobility and end stage disease, and included weekly skin inspection and incontinent care. Resident #3 had diagnoses including Alzheimer’s disease, hypertension, atherosclerotic heart disease, varicose veins with complications, lymphedema, edema, and protein calorie malnutrition. Resident #3 required maximum assistance with rolling, toileting, dressing, and personal hygiene, and the care plan identified impaired cognition, decreased mobility, nutritional problems, and pressure ulcer potential. Resident #4 had dementia, anxiety, protein calorie malnutrition, hypertension, and chronic heart failure, with a care plan noting potential for pressure ulcer development related to decreased mobility and incontinence. Record review showed the weekly skin assessments for these residents were not completed on a consistent weekly basis. Resident #1’s skin checks were documented more than 7 days apart, and Resident #3 and Resident #4 also had gaps in weekly skin assessment documentation. During observation, Resident #1 was in bed with a new dressing to the right heel and grimaced when moved, and Resident #3 was observed with a new red area on the foot and skin sheering at the sacral area. Staff interviews confirmed the skin assessments were expected per facility policy, but were not consistently completed or charted, and leadership was unable to provide evidence that monitoring systems were effective in ensuring compliance with skin assessment protocols.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
The facility failed to ensure Resident #2 was treated with respect and dignity when personal care was provided with the room door open on 5/5/2026. Resident #2 had been admitted on 12/23/2025 with diagnoses including unspecified dementia, monoclonal gammopathy, and end stage renal disease. Her MDS assessment dated 03/27/2026 showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and her care plan identified an ADL self-care performance deficit related to impaired cognition and debility. During observation at 9:12 AM, CNA C and HA E were seen providing personal care to Resident #2 with the door open, and Resident #2 was observed completely naked in her bed from the hallway. In interviews, Resident #2 stated she would be bothered if the door were left open during care. HA E stated staff should close the door to ensure privacy and acknowledged that leaving it open could affect dignity and be embarrassing. CNA C stated the door should not have been left open and said the situation happened quickly because of the shower bed in the room and because the hospitality aide was present for observation. The ADM stated it was her expectation that staff provide privacy during care and at a minimum pull the privacy curtain and close the door.
Nonfunctioning Resident Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was functioning for one resident who had an admission date of 12/13/2024 and diagnoses including Alzheimer's disease, anemia, and depression. The resident's MDS assessment dated 03/26/2026 showed a BIMS score of 4 out of 15, indicating significant cognitive impairment. During observation on 05/05/2026 at 11:05 AM, the resident was sitting in bed and stated she needed help but then said she did not remember what she needed help with. She said she could call staff by pressing the button on her tray table, but the button was observed not attached to anything. When the resident pressed the button, surveyor testing showed it did not alert staff. At 11:30 AM, a CNA/medication aide stated the call button should work and that it rings at the nurses station, but it was not responding. A maintenance technician then tested the device at the nurses station and confirmed it did not alert there. He stated the call button was not working and provided a new one that worked immediately. Interviews on 05/06/2026 showed the ADM stated the facility had no policy on call buttons and followed state regulations, staff had not been given guidance for routine checks unless a resident reported an issue, and the maintenance technician stated the new call system had been in place for about one month and that he had not followed up to ensure all residents had received new replacement buttons.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, CNAs directly responsible for resident care per shift, and the resident census for 2 of 2 days reviewed. Surveyors observed that on 05/05/2026 a posting dated 04/28/2026 was displayed outside the ADM’s office, and on 05/06/2026 a posting dated 05/05/2026 was displayed in the same location. The report states the facility did not have the required current nurse staffing and census information posted from 04/29/2026 to 05/05/2026. During interviews, the ADM stated the facility did not have a policy on daily nurse staffing and census posting and said the facility followed state regulations. The DON, who had been at the facility for only two weeks, stated she had not previously been involved with the postings and that the ADON had only been designated to complete them 3 to 4 days earlier. The ADON stated she was new to the position, had recently received training on posting the staffing information, and posted the staffing information late that morning. The ADM stated the nursing department, specifically the ADON and the charge nurse on weekends, was responsible for the daily postings and acknowledged the posting had been overlooked.
Failure to Care Plan Mattress Use and Crawling Behavior for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and timeframes that reflected a resident’s identified needs and behaviors. The resident was an elderly male with Alzheimer’s disease with late onset, abnormalities of gait and mobility, bipolar disorder with severe depressive episode and psychotic features, generalized muscle weakness, and a prior cerebral infarction. His Quarterly MDS showed he was unable to complete the BIMS, had poor short- and long-term memory, severely impaired decision-making, difficulty focusing, and disorganized thinking. He required at least supervision or touching assistance for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers. Despite these needs and cognitive impairments, his Comprehensive Care Plan dated 01/19/2026 and revised on 02/05/2026 did not include that he had a mattress beside his bed, that he lay on this mattress, or that he crawled off the mattress toward his roommate’s bed. Nursing documentation showed repeated observations of the resident lying on a mattress on the floor next to his bed and engaging in crawling behavior toward his roommate’s bed, but these observations were not incorporated into the care plan. Nurse notes on 01/31/2026 at multiple times documented the resident lying on a mattress on the floor parallel to his bed. Additional nurse notes on 02/02/2026 documented that the resident was not staying on the mattress, crawled off it twice, and was observed crawling toward his roommate’s bed, and later that he rolled off the mattress onto the floor and toward the roommate’s bed, awakening the roommate. None of these behaviors or the use of the mattress on the floor were reflected in the resident’s care plan, and therefore were not communicated through the care plan to guide staff interventions. Interviews with facility staff confirmed that the behavior and mattress use should have been care planned and that the care plan is the source of information for the CNA Kardex. The MDS Coordinator stated that if a resident had a mattress beside the bed and was crawling off it toward a roommate’s bed, this behavior was expected to be care planned, and acknowledged that the care plan is used to inform staff how to provide needed care and interventions. The DON and Administrator both stated their expectation that such a mattress and related behaviors be included on the care plan, and that CNA Kardex information comes from the care plan. A CNA/MA reported that the resident had a mattress on the floor by his bed for approximately two weeks before he died, that he preferred lying on the mattress, and that he began to crawl toward his roommate’s bed, but she did not recall seeing this on the Kardex. An LVN reported she had not been trained on how to document or revise care plans despite working at the facility for over a year, while another LVN stated she had been trained at a different facility owned by the same company. The Nurse Consultant stated all nursing staff had been in-serviced on documenting care plans but could not provide dates or documentation of such training. The facility’s written policy stated that care plans would be reviewed and revised based on changing goals, preferences, and needs, but the resident’s mattress use and crawling behavior were not added to the care plan despite repeated documentation in the nurse notes.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide an ongoing activity program to support residents' choices and needs for both group and individual activities, as well as independent activities, for the entire months of August and September 2025. Record review showed there were no activity participation records for these two months, and the Activity Director confirmed that there was no documentation of any activities provided during this period. The absence of activities was also corroborated by resident interviews, with multiple residents reporting a lack of activities and expressing feelings of boredom during this time. Three residents were specifically reviewed in relation to this deficiency. One resident, with diagnoses including major depressive disorder and other depressive disorders, reported feeling bored and stated that there were approximately two or three months with very few activities, except for reading and watching TV. Another resident, with mild intellectual abilities and major depressive disorder, stated that there were months with no activities except for occasional church services, though he did not get bored due to personal activities and family support. A third resident, diagnosed with bipolar disorder and generalized anxiety disorder, also reported periods without visible activities and occasional boredom, though he preferred solitary activities and sometimes attended music events or parties. The Activity Director, who had been certified and in her role for over ten years, admitted to not providing or documenting activities during the deficient months and did not request assistance. The Administrator was unaware of the lack of documentation until October 2025, as she had not yet monitored the activity department. The facility's job description for the Activity Director included maintaining detailed records of activity programs and participation, which was not fulfilled during the months in question.
Failure to Provide Appropriate Psychiatric Services for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental illness, psychosocial adjustment difficulties, or a history of trauma and/or post-traumatic stress disorder received appropriate treatment and services to address their assessed problems and attain the highest practicable mental and psychosocial well-being. Specifically, three residents with significant behavioral health needs did not receive adequate psychiatric services. The deficiency was identified through interviews and record reviews, which revealed gaps in the provision of individualized psychiatric care and counseling. One resident with severe dementia, anxiety disorder, alcohol-induced persisting dementia, and a history of trauma exhibited multiple behavioral issues, including wandering, aggression, inappropriate exposure, and self-injurious behaviors. Although the care plan included interventions such as arranging for a licensed mental health provider and monitoring for escalating symptoms, documentation showed ongoing behavioral challenges and repeated psychiatric notes that primarily focused on medication management. The psychiatric provider's notes often indicated that non-pharmacologic interventions had been ineffective, but there was little evidence of ongoing, individualized psychiatric counseling or assessment of the resident's emotional state in relation to recent incidents. Another resident with major depressive disorder and chronic diarrhea reported feeling that psychiatric visits were superficial and did not address his emotional needs or recent conflicts with a roommate. He stated that the psychiatrist did not inquire about his feelings or the impact of recent altercations, and that visits were conducted in the presence of his roommate, making him uncomfortable to share openly. A third resident with mild intellectual disabilities, major depressive disorder, and generalized anxiety disorder also reported that psychiatric visits did not address his behavioral outbursts or emotional well-being, with interactions focusing on casual topics rather than his mental health needs. These findings demonstrate a lack of comprehensive psychiatric assessment and individualized counseling for residents with behavioral health needs.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent one resident from physically assaulting another. One resident, who had a history of major depressive disorder and chronic diarrhea, was involved in a conflict with his roommate, who had diagnoses of bipolar disorder with psychotic features and generalized anxiety disorder. The conflict escalated due to ongoing arguments about hygiene and odor related to the first resident's medical condition. Despite both residents having intact cognition, their interpersonal issues were not identified or addressed by staff prior to the incident. On the day of the incident, the resident with chronic diarrhea exited the bathroom and discussed showering with a CNA, while his roommate overheard the conversation and became increasingly agitated. The agitated resident followed his roommate to the therapy room, where he began yelling and cursing. Therapy staff attempted to verbally de-escalate the situation by asking the agitated resident to calm down and go for a walk, but these interventions were ineffective and further escalated his anger. The resident then approached his roommate, who was seated, and struck him in the nose. Staff present in the therapy room did not physically intervene to prevent the assault, and the assaulted resident later expressed that if someone had stepped in front of him, he would not have been hit. Interviews with staff revealed that they were unaware of any prior arguments between the two residents and did not anticipate the escalation. The Director of Therapy acknowledged that the interventions used were not appropriate and that removing the assaulted resident from the situation would have been a better response. The facility's policy on abuse and neglect emphasizes the responsibility of staff to recognize and promptly intervene in situations that may constitute abuse, but in this case, staff failed to protect the resident from physical harm.
Failure to Secure Shower Room and Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards by not keeping the shower room door on one hallway closed and locked as required. During an observation, the shower room door was found propped open with no staff or residents nearby, and various potentially hazardous items such as no-rinse cleanser, shampoo, body wash, and shaving cream were accessible on top of a clothes barrel. Staff interviews confirmed that the expectation was for the shower room door to be locked at all times, and that staff had been in-serviced on this requirement, though the last in-service date could not be recalled. The CNA involved admitted to leaving the door unlocked and acknowledged the risks associated with residents accessing the chemicals inside. Further interviews with the DON and Administrator confirmed that all shower doors were expected to be closed and locked at all times to prevent residents from entering unsupervised, potentially ingesting chemicals, or being unable to call for help if they fell. The Administrator also stated that there was no formal protocol in place for accidents and hazards. A review of the Safety Data Sheet for one of the cleansers indicated that ingestion could be harmful, and the facility was unable to provide Safety Data Sheets for other chemicals present in the shower room.
Failure to Prevent Pressure Ulcers Under Cervical Collar
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent pressure ulcers for a resident with a cervical collar (C-collar). The resident, who had diagnoses including dementia, vertebral artery dissection, and cervical vertebra fractures, was admitted and readmitted to the facility without any initial evidence of pressure ulcers. Physician orders specified that the C-collar should be worn at all times except during showers, with a soft collar to be used for bathing. However, there were no orders or documented interventions for regular removal of the collar to perform skin checks, and the care plan did not address brace removal for skin assessment. Observations and interviews revealed that staff did not consistently remove the C-collar to assess the skin underneath, as required by facility policy and professional standards. The collar was found to be taped in place, with excessive tape wrapped around it, and was soiled with fecal matter and food. Nursing staff, including the treatment nurse and LVNs, reported not removing the collar for thorough skin assessments, and some staff were unaware of the presence or purpose of the tape. The resident was only documented as receiving baths on two occasions, and during these times, the collar was not always removed. When the resident was sent to the emergency room, hospital staff discovered unstageable pressure ulcers, wounds behind the ear and on the chin, and noted a strong odor and signs of infection under the collar. Interviews with facility staff and the resident's physician confirmed that proper procedures for skin assessment under immobilization devices were not followed. The physician stated that the collar should be fitted correctly and removed for skin checks as appropriate, and the facility's own policies required periodic removal of immobilization devices for skin assessment and cleanliness. Despite these requirements, staff failed to perform adequate skin checks, did not document concerns about the tape or soiling, and did not follow up with appropriate interventions to prevent pressure ulcers. These failures resulted in the development of unstageable pressure ulcers and an Immediate Jeopardy situation.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Unattended Unlocked Medication Cart Found in Hallway
Penalty
Summary
A deficiency occurred when a medication cart on [NAME] Hall was found unlocked and unattended near the nurse's station and hallway entrance. The state surveyor observed that the locking mechanism was protruding outward, and the drawers containing medications and biologicals could be opened. No nursing or other staff were present in the area at the time of observation. RN A later confirmed that he had left the cart unlocked while assisting with a resident transfer in a room where the cart was not visible. He acknowledged that the cart should have been locked at all times except when dispensing medications and that it was his responsibility to ensure its security. The key to the cart was in his pocket, and he stated that narcotics, PRN medications, a glucose monitor, and a blood pressure cuff were stored in the cart. Interviews with the Director of Nurses and the Administrator confirmed that their expectation was for all medication carts to be locked when not in use and that staff had been in-serviced on this policy, though neither could recall the specific date of the in-service. Both acknowledged that leaving the cart unlocked could allow residents, staff, or visitors access to medications. Review of the facility's policy indicated that medications and biologicals are to be stored securely and only accessible to authorized personnel, with medication carts to be locked or attended at all times.
Failure to Provide Accessible Grievance Process Information
Penalty
Summary
The facility failed to ensure that residents had accessible and adequate information regarding their right to voice grievances without discrimination or reprisal. Observations revealed that the grievance procedure was posted in only two locations: one near the front entrance, affixed approximately nine feet above the floor, making it difficult for residents—especially those in wheelchairs or of shorter stature—to read, and another behind the nurse's station desk, in an area not accessible to residents. A walkthrough of the facility confirmed that these postings were not positioned in a way that supported easy viewing or access by residents, their representatives, staff, or visitors. Additionally, there was no evidence that grievance forms or instructions for filing anonymous grievances were readily available to residents. Interviews with five of six residents indicated that they had not received information about the process for filing grievances or concerns within the facility. These residents reported being unaware of their right to formally voice concerns or complaints and did not know who to contact or where to find grievance forms or related resources. The facility's Grievance Policy required that residents be notified on how to file a grievance orally, in writing, or anonymously, with postings in prominent locations, but this was not being met in practice.
Failure to Provide Necessary ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One male resident with Alzheimer's disease and cerebral infarction, who was on hospice care, was observed to have long, jagged fingernails with brown debris underneath. His care plan indicated a need for supervision or assistance with personal hygiene, but staff were unaware of their responsibility to provide this care. A female resident with type 2 diabetes, morbid obesity, and a history of stroke was dependent on staff for personal hygiene. Documentation showed that she did not consistently receive scheduled baths, with five missed or undocumented baths in one month. She also reported that her nails were not trimmed as requested, and staff were not aware of the need to provide this care. Another female resident with dementia and psychotic disturbance was also dependent on staff for personal hygiene. She was observed wearing the same stained clothing for three consecutive days and had long, dirty, jagged fingernails. Bathing records indicated that eight scheduled baths were not documented as given in one month. Staff interviews confirmed a lack of training and awareness regarding the importance of regular hygiene, nail care, and clothing changes for residents who are unable to care for themselves.
Failure to Monitor and Record Daily Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident received daily vital sign monitoring as ordered by a physician and as part of a QAPI initiative to prevent rehospitalization. The resident, an elderly female with severe dementia, hypertension, and generalized anxiety disorder, had physician orders for daily vital signs, including blood pressure, pulse, temperature, respiration, and oxygen saturation, starting from late March. Despite these orders, there were 58 days within a 68-day period where no vital signs were recorded for the resident. Record reviews confirmed that the resident's care plan included monitoring for abnormal blood pressure due to cardiac disease, and medication orders for antihypertensive drugs were in place. However, documentation showed that vital signs were not consistently obtained or recorded, and direct observation revealed that staff did not take blood pressure or pulse prior to administering blood pressure medication. Interviews with nursing staff and medication aides indicated confusion regarding responsibility for obtaining vital signs, with some staff believing the order was no longer valid or that it was the nurse's responsibility rather than the medication aide's. Further interviews with nursing leadership revealed that the QAPI order for daily vital signs was not set up correctly in the system, which prevented proper tracking and auditing. The responsible nurse who initiated the order was no longer employed at the facility, and there was no specific policy for vital signs beyond following physician orders. The lack of daily vital sign monitoring as ordered was acknowledged by both nursing and administrative staff, who recognized the potential for unacknowledged changes in condition and possible hospitalization.
Failure to Ensure Dietary Staff Wore Hair Restraints During Food Preparation
Penalty
Summary
A deficiency was identified when a Dietary Aide was observed in the kitchen preparing dessert and washing dishes without wearing a hair restraint. The aide acknowledged during an interview that she was aware of the requirement to always wear a hair net, as she had been trained by a previous Dietary Manager and held a food handler certificate. She explained that she found a hair net on the floor but did not realize her own had fallen off. The Dietary Manager confirmed that it was expected for all dietary staff to wear hair restraints before entering the kitchen and noted that the aide's hair net often fell off due to its size. The facility had signage at the kitchen entrance reminding staff to wear hair nets, and the infection control policy required clean hair to be covered with an effective hair restraint. Interviews with both the Dietary Manager and the Administrator confirmed the expectation that all dietary staff must wear hair nets in the kitchen. The facility's infection control policy, dated 04/09/2025, specified that personal cleanliness and the use of hair restraints were required to maintain sanitary food preparation. The failure to ensure the Dietary Aide wore a hair net while handling food and dishes constituted a breach of professional standards for food service safety.
Loose Controlled Medication Found in RN Medication Cart
Penalty
Summary
A deficiency occurred when a loose Tramadol 50 mg pill, a controlled medication, was found unsecured in the bottom drawer of a locked RN medication cart during an observation. The pill was identified by an RN, who confirmed it was not properly secured, administered, or disposed of according to facility policy. The RN stated that it was the responsibility of staff administering medications to check their carts before use, and that all medication counts had been correct that morning. There were no previous discrepancies reported with the narcotics count, including Tramadol, and the RN indicated she would complete an incident report regarding the loose medication. Interviews with nursing leadership, including the RCN, ADON, and Traveling DON, confirmed that the presence of a loose controlled medication in the cart could mean a resident did not receive their prescribed pain medication, and there was potential for diversion. An audit was performed for the two residents prescribed Tramadol, and the counts were found to be correct, suggesting the pill may have fallen out during preparation. The facility's policy requires controlled substances to be handled in accordance with federal and state laws, with only authorized personnel having access. The ADM stated that controlled medications should be kept in a lock box and that the loose pill in the cart indicated a resident may not have received their ordered medication.
Failure to Provide Dental Services for Resident with Oral Health Needs
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident with significant oral health needs. The resident, a 69-year-old woman with diagnoses including Parkinson's disease, protein-calorie malnutrition, and rhabdomyolysis, had no natural teeth and experienced pain when eating certain foods. Despite a care plan identifying her risk for oral health problems and a physician order for a dental consult as needed, there was no evidence that a dental consult was arranged or that the resident was seen by a dentist during her stay. Record reviews showed that the resident's quarterly MDS assessment did not reflect mouth or facial pain, but the resident herself reported difficulty chewing and pain with hard foods during an interview. She stated she had not seen a dentist in three years, including the duration of her stay at the facility. Staff interviews revealed a lack of clarity and follow-through regarding the process for dental referrals, with social services, nursing, and administration each describing different responsibilities for ensuring dental care was provided. The resident was not added to the list for the mobile dental service, and there was no documentation of a dental exam or consult in her records. The facility's policy required that oral health services be available and that social services assist with dental appointments and transportation, following notification from nursing. However, the breakdown in communication and lack of action resulted in the resident not receiving the dental care outlined in her care plan and physician orders. This failure was identified through observation, interviews, and record review, and directly affected the resident's ability to eat comfortably and maintain oral health.
Failure to Use Gloves During Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use gloves while opening Depakote Sprinkles capsules for a resident during medication administration. The resident involved was an elderly female with severe dementia, essential hypertension, and cognitive communication deficits, who required supervision with eating and drinking. The resident's care plan included interventions for medication administration and monitoring for signs and symptoms of dysphagia. Despite facility policy and accepted infection control standards requiring glove use to prevent cross contamination, the LVN did not wear gloves when opening the capsules. Multiple staff interviews, including those with a medication aide, the LVN involved, the registered charge nurse (RCN), the director of nursing (DON), and the administrator (ADM), confirmed that the expected practice was to wear gloves during this procedure. The facility's infection control policy also specified glove use to reduce the risk of transmitting microorganisms. The failure to follow these procedures was observed directly and acknowledged by staff as a breach of infection control practices, potentially exposing the resident to cross contamination.
Failure to Provide Accessible Survey Results to Residents and Representatives
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by Federal or State surveyors, as well as any plan of correction in effect. During an observation, the survey results book was found placed behind a plant stand, making it difficult to locate or access. The book was not readily accessible or visible to residents, their legal representatives, or visitors. Additionally, the survey book only included the results from one survey and did not contain reports or plans of correction for the three preceding years as required. During a confidential group interview, six residents stated they were unaware of the existence of the survey book or how to access the survey results. The Administrator (ADM) confirmed it was her responsibility to maintain and update the survey book but was unaware of the requirement to include survey, certification, and complaint investigation reports, as well as plans of correction for the past three years. The ADM also stated she could not find a written policy regarding the maintenance and accessibility of the survey book.
Failure to Maintain Sufficient Nurse Staffing on Multiple Shifts
Penalty
Summary
The facility failed to provide sufficient numbers of nurse aides and licensed nurses on a 24-hour basis to meet the needs of all residents, as required by posted nurse staffing levels and resident care plans. Over a period of several days, staffing schedules and time punches revealed repeated shortfalls in both nurse aides and licensed nurses on multiple shifts, with the facility consistently missing the required number of staff as indicated by their own posted staffing requirements. The resident census during this period was 58, and the facility assessment confirmed this average census. Despite the posted requirements, actual staffing often fell short, with some shifts missing up to two nurse aides and one LVN. Resident council minutes and interviews with residents indicated that call lights were not answered in a timely manner and that scheduled showers were sometimes missed. Multiple residents reported delays in receiving assistance and noted that staff were overworked, with some residents stating they had to remain in bed due to insufficient staff to assist them. Staff interviews corroborated these findings, with several staff members reporting chronic understaffing, frequent call-ins, and high turnover due to low pay and overwork. Staff also reported that nurses and therapy staff had to assist with direct care tasks to compensate for the lack of nurse aides, which in turn prevented them from completing their own duties, such as charting. The facility's own policy and facility assessment required staffing decisions to be informed by resident needs and census, and to include contingency planning for staffing shortages. However, interviews with the Director of Rehabilitation, acting administrator, and multiple staff members confirmed that the facility was unable to maintain adequate staffing, particularly when scheduled staff called in or did not show up. The issue was widely known among staff and residents, and the facility struggled to recruit and retain staff, with sign-on bonuses and pay rates cited as contributing factors. Observations during the survey period showed that, while care was being provided and call lights were answered promptly during the survey, this was not representative of typical staffing levels, as staff reported that the facility was only fully staffed due to the presence of surveyors.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodations for their needs, specifically regarding the accessibility of call lights. Three residents were affected by this deficiency. Resident #1, a female with Alzheimer's Disease and severe cognitive impairment, was found with her call light behind her bed and out of reach. She was unaware of its location and unable to reach it, despite her care plan indicating that the call light should be within reach due to her communication problems and cognitive deficits. Similarly, Resident #2, a male with hemiplegia and moderate cognitive impairment, had his call light positioned behind his bed, making it inaccessible. He expressed that he often had to wait for staff to pass by for assistance. Resident #3, a female with unspecified dementia and aphasia, also had her call light out of reach, as it was found on the floor beside her recliner. She was unaware of its location and unable to reach it. Interviews with staff, including a CNA and the DON, confirmed that call lights should always be within reach, yet this was not consistently ensured, leading to the deficiency.
Failure to Include Psych Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not include the psych services the resident was receiving. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, an elderly female with diagnoses including unspecified dementia, major depressive disorder, and aphasia, had a physician order for psych services to evaluate and treat as needed. Despite this, the resident's care plan did not reflect these services, which were documented in psych service notes indicating the resident was seen on two occasions. Interviews with the Director of Nursing (DON) and the Registered Nurse Coordinator (RCN) confirmed that the resident was receiving psych services and that these should have been included in the care plan. Both the DON and RCN acknowledged the absence of a Minimum Data Set (MDS) coordinator and stated that it was the responsibility of the Interdisciplinary Team (IDT) to ensure the care plan was accurate. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but this was not adhered to in this case.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan was not updated to reflect the resident's recent falls on three separate occasions. The resident, who has severe cognitive impairment and is dependent on assistance for various activities of daily living, experienced falls on 12/20/2024, 01/24/2025, and 01/26/2025. Despite these incidents, the care plan did not include these falls, which could potentially impact the resident's care. Interviews with the Director of Nursing (DON) and the Registered Charge Nurse (RCN) revealed that the care plan should have been updated after each fall to ensure the resident received the most efficient care. The RCN noted that without a current MDS coordinator, it was the responsibility of the interdisciplinary team to update the care plan. The facility's Comprehensive Care Planning policy requires that care plans be reviewed and revised based on changing needs and interventions, but this was not adhered to in the case of the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily and was readily accessible to residents and visitors, as required. This deficiency was observed over a period of seven days, from January 24, 2025, to January 30, 2025. During this time, the nursing staffing information was not updated and remained dated January 23, 2025. The Director of Nursing (DON), who was new to long-term care, was unaware of the requirement to post this information. The facility also lacked a policy regarding the posting of nursing staff information, contributing to the oversight. Interviews with the DON and the RCN revealed that the responsibility for posting the staffing information was not clearly communicated, especially during the absence of the administrator due to illness. The RCN indicated that the administrator had been responsible for posting the information, and with the administrator out sick, the DON, who was not informed of this duty, did not ensure the information was posted. The RCN also mentioned that the weekend supervisor was responsible for posting on weekends, but this was not done. Both the DON and RCN stated that the lack of posted information would not adversely affect residents, although it was meant to demonstrate staffing transparency.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately inform a resident's physician and notify the resident's representative when there was a significant change in the resident's physical status. The resident, a female with a history of cerebral infarction, type II diabetes, muscle weakness, and lack of coordination, experienced swelling and pain in her left arm. Despite the resident's complaint of severe pain and visible swelling, the physician was not notified until several days later when the physician was on-site for rounds. On November 16, the resident reported a pain level of 10 out of 10, and interventions such as Tylenol and Voltaren Gel were administered, providing temporary relief. However, the physician was not informed of this significant change. It was only on November 20, when the physician was present at the facility, that an x-ray was ordered. The x-ray results, which showed no significant findings, were not communicated to the physician. The resident's condition worsened, leading her to request an emergency room visit on November 26, where she was diagnosed with a ruptured left bicep tendon. Interviews with the staff revealed a lack of communication and adherence to the facility's policy on notifying physicians of significant changes in a resident's condition. The Director of Nursing acknowledged that the physician should have been notified immediately about the swelling and increased pain. The physician expressed that had she been informed earlier, she would have sent the resident to the emergency room sooner. This oversight in communication and notification could have placed the resident at risk of further complications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, as outlined in the resident's care plan. The resident, who has a history of military service-related PTSD, was placed in a shared room with another resident, despite the care plan explicitly stating that having a roommate triggers the resident's PTSD. This oversight was identified during a review of the resident's care plan, which had been revised to include the need for a private room to prevent re-traumatization. Interviews with facility staff, including an LVN, the MDS Coordinator, the Social Worker, the DON, and the Regional Compliance Nurse, revealed a lack of awareness and adherence to the resident's care plan. The LVN was unaware of the resident's PTSD diagnosis and the associated care plan requirements. The MDS Coordinator acknowledged the failure to follow the care plan, which could lead to adverse effects, including potential physical altercations or re-traumatization. The Social Worker and the DON also confirmed that the resident's PTSD and triggers should have been care planned and followed through with, emphasizing the importance of adhering to the care plan to prevent negative outcomes. The facility's Trauma-Informed Care Policy mandates the identification and mitigation of triggers for residents with a history of trauma. However, the policy was not effectively implemented in this case, as evidenced by the resident's continued placement in a shared room. The facility's failure to adhere to the care plan and policy guidelines placed the resident at risk for psychological distress and re-traumatization, highlighting a significant deficiency in the provision of trauma-informed care.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident who was at risk for skin breakdown. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was left in the same position in a Geri-chair for six and a half hours without being turned or provided with incontinent care. This neglect led to the development of two deep tissue injuries (DTIs) on the resident's coccyx, which were previously unidentified by the facility. The resident's care plan included interventions to prevent skin breakdown, such as checking the resident every two hours and assisting with toileting as needed, as well as repositioning to prevent pressure on body parts. However, these interventions were not followed, as evidenced by the resident being left in the same position for an extended period. The facility's policy on pressure injury prevention and perineal care was not adhered to, resulting in the resident's skin breakdown. Interviews with staff revealed that the certified nursing assistant (CNA) responsible for the resident did not perform the necessary care due to being alone on the hall and not seeking assistance. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the resident's prolonged time in the chair, and the facility's monitoring systems failed to identify and address the issue in a timely manner.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for residents' monthly resident council meetings, which compromised the residents' ability to voice their grievances in a confidential setting. The meetings were initially held in the dining area, an open room next to the nurses' station without doors, which did not ensure privacy. This arrangement was confirmed by the Administrator during an interview, who acknowledged the lack of privacy in the current meeting location. A confidential resident group meeting was later held in the Activity Director's office, where residents expressed their discomfort with the usual meeting space in the dining room due to its lack of privacy. The residents indicated that they do not meet regularly and would prefer a private setting. The newly appointed Activity Director also confirmed that meetings should be held in a room with a door, such as the activity room, to ensure privacy. Additionally, the facility was unable to provide Resident Council minutes or a copy of the Resident Council Policy when requested by the surveyors.
Deficiencies in ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) to residents who were unable to perform them independently. Specifically, the facility did not ensure that two residents received repositioning and incontinent care every two hours as required. Observations revealed that these residents were left in the same position for extended periods, resulting in saturated briefs with a strong urine odor. Interviews with staff indicated that the care was not provided due to a lack of assistance, and the staff did not seek help to perform the necessary care. Additionally, the facility failed to maintain proper nail hygiene for three residents, resulting in a blackish substance accumulating under their fingernails. These residents required assistance with personal hygiene due to cognitive and physical impairments. Despite requests from one resident to have their nails cleaned, the care was not provided. Interviews with staff revealed a lack of awareness and responsibility for nail care, with confusion over whether CNAs or nurses were responsible for cleaning the nails of diabetic residents. The deficiencies in providing ADL assistance and nail care placed residents at risk for health-related issues, including potential infections and skin breakdown. The facility's policies on perineal and nail care were not followed, leading to a decline in the quality of care provided to the residents. The observations and interviews highlighted a lack of communication and accountability among staff, contributing to the failure to meet the residents' needs.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessment and care plan of each resident, as well as their preferences. This deficiency was observed in four residents who were not receiving one-on-one activities or participating in group activities over a four-month period. The lack of engagement in activities could potentially lead to a decline in their social, mental, and psychosocial well-being, as well as a diminished quality of life. Resident #4, a female with diagnoses including unspecified dementia, hemiplegia, cerebrovascular disease, and aphasia, was not receiving the one-on-one sensory stimulation activities outlined in her care plan. Observations showed that she spent significant time in her room with minimal stimulation, such as a television being on. Similarly, Resident #20, who had multiple sclerosis, dementia, major depressive disorder, and anxiety, was not engaged in activities that matched her interests, such as listening to music or participating in religious activities. Observations confirmed that she was often in her room with the television on, without any other form of stimulation. Resident #21, diagnosed with depression, anxiety, and dementia, also did not receive the one-on-one activities or group engagement specified in her care plan. She was observed in her room with the television on, lacking the socialization and sensory stimulation needed. Resident #61, who was legally blind, deaf, and non-verbal, was not provided with appropriate tactile sensory activities, as she consistently rejected the cloth activity item given to her. Staff interviews revealed a lack of alternative activities being offered to her, and she was often seen pacing or sitting without engagement. The facility's administrator acknowledged the absence of documented activities for these residents and recognized the potential negative impact on their well-being.
Deficiency in Puree Food Preparation
Penalty
Summary
The facility failed to prepare pureed food by methods that conserve nutritive value, flavor, and appearance, specifically in the preparation of pureed meatloaf. Observations revealed that staff members were using water instead of broth or thickener to puree meatloaf, which is against the facility's puree diet recipes. Staff members did not have the recipes available during food preparation, and one staff member admitted to forgetting to use them. Interviews with staff indicated a lack of understanding of the negative outcomes of using water, which can dilute the nutritional content of the food. The facility's Administrator confirmed that staff were trained on puree preparation and that recipes were available, but they were not being utilized. The Administrator acknowledged that using water instead of broth or thickener could result in residents not receiving the necessary nutrition. Despite the availability of recipes and training, staff members were not following the correct procedures, leading to the deficiency in food preparation. The facility was unable to provide the puree policy upon request during the survey, indicating a possible gap in policy enforcement or availability.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation, as observed during a survey of the kitchen. Specifically, food items in the walk-in cooler, freezer, and dry storage were not labeled or dated, which is a critical step in ensuring food safety. Milk, apple juice, and orange juice in the cooler, as well as dough and sausage patties in the freezer, lacked proper labeling. Additionally, a container of flour in the dry storage area was not dated. This oversight was confirmed through interviews with staff members, who acknowledged the importance of labeling and dating food items to prevent the risk of foodborne illness. Furthermore, the facility did not maintain proper food temperatures before placing items on the steam table. During an observation, the temperature of pureed meatloaf was recorded at 120 degrees Fahrenheit, and pureed peas at 142 degrees Fahrenheit, both below the required temperatures for safe consumption. Staff members, including the dietary aide and food service supervisor, were aware of the correct temperature requirements but failed to ensure compliance. The administrator and other staff members recognized the potential risk of bacterial growth and illness due to improper food labeling and temperature control.
Resident Dignity Compromised During Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident during a meal service in one of the dining rooms. The incident involved a resident who was not served his lunch tray for 20 minutes after his tablemate had already begun eating. This delay in service led to the resident expressing feelings of hunger and frustration, as he repeatedly asked for food and questioned why he had not been served. Observations noted that staff were present in the vicinity but did not address the resident's needs promptly, contributing to the resident's agitation. The resident in question had a history of intermittent explosive disorder and was assessed to have poor short- and long-term memory recall. His care plan indicated a potential for verbally and physically abusive behaviors, with interventions in place to assess and anticipate his needs to prevent agitation. Despite these measures, the resident was left to watch his tablemate eat, which led to visible signs of anger and distress, such as clenched fists and tense facial expressions. The staff's inaction in serving the resident in a timely manner was a direct violation of his right to dignity and respect. Interviews with staff revealed a lack of communication and coordination between the nursing and dietary departments regarding meal service. The staff were expected to serve all residents at one table before moving to another, but this protocol was not followed. The failure to communicate the resident's dining location to the dietary staff resulted in the delay of his meal service. The facility's policy on dining room etiquette was not adhered to, leading to the resident feeling ignored and potentially isolated, which could have exacerbated his behavioral issues.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #45 and Resident #46, were within their reach, which is a deficiency in accommodating the needs and preferences of residents. Resident #45, a male with essential tremor, unspecified dementia, and other conditions, was observed lying in bed without access to his call light, which was placed on a nightstand 3-4 feet away. He expressed difficulty in reaching the call light and fear of injury if he attempted to do so. His care plan indicated a need for assistance with activities of daily living (ADLs) and communication problems. Resident #46, a female with lymphedema, major depressive disorder, and other health issues, was found sitting in her recliner without her call light in reach, as it was positioned behind the recliner. She expressed reliance on the call light for assistance and concern about falling if she attempted to get up without help. Her care plan highlighted her risk for falls and poor safety awareness, requiring staff assistance with ADLs and ensuring the call light was within reach. Interviews with staff, including an LVN, ADON, CNA, and the Administrator, revealed a consensus that it was the responsibility of all staff to ensure call lights were accessible to residents. They acknowledged the potential risks of falls and injuries if residents attempted to reach for call lights that were not within reach. Despite being in-serviced on the importance of call light placement, staff could not recall the last training date, and the facility's policy on call lights was not provided upon request.
Failure to Include Indwelling Urinary Catheter in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter. The care plan did not reflect the resident's use of the catheter, instead incorrectly noting bladder incontinence. This oversight was identified during a review of the resident's records, which included a physician's order for a urinary catheter and a quarterly MDS assessment indicating the presence of the catheter. The resident, who has severe cognitive impairment and multiple diagnoses including dementia and benign prostatic hyperplasia, was observed with the catheter drainage bag improperly placed on the floor. The Director of Nursing (DON) acknowledged the omission in the care plan, stating that the care plan should have addressed the catheter and not mentioned bladder incontinence. The DON admitted that the facility did not have a dedicated person for care plans, and the responsibility fell on her and the Assistant Director of Nursing (ADON). The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Implement Contracture Management Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion for two residents with hand contractures. Resident #4, a female with severe cognitive impairment and multiple medical conditions including dementia and hemiplegia, was observed without the necessary splints or palm guards for her bilateral hand contractures. Her care plan included interventions such as applying a right wrist cock-up splint and a left padded palm guard, as well as providing gentle stretching and range of motion exercises. However, observations revealed that these interventions were not in place, and her fingernails were long and untrimmed. Interviews with staff indicated that due to short staffing, these care interventions were not consistently implemented. Resident #20, another female with severe cognitive impairment and conditions such as multiple sclerosis and hemiplegia, was also found without the necessary contracture management devices. Her care plan did not include specific interventions for her contracted right hand, although she was receiving skilled occupational therapy services. Observations showed that her therapy carrot, a device meant to aid in contracture management, was not consistently placed in her hand. Staff interviews revealed that the therapy carrot was often removed by the resident and not promptly replaced by the staff. The facility's failure to ensure the implementation of prescribed interventions for residents with contractures placed them at risk for decreased mobility and worsening of their condition. The Director of Nursing acknowledged the expectation for staff to perform range of motion exercises and ensure the use of devices to prevent further decline. The facility's policy on immobilization devices emphasized the need for regular monitoring and documentation, which was not adhered to in these cases.
Inadequate Catheter Care Leading to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to potential risks for urinary tract infections. The resident, who has severe cognitive impairment and multiple medical conditions including dementia and benign prostatic hyperplasia, was observed with his catheter drainage bag placed on the floor on multiple occasions. The facility's care plan did not address the issue of the urine collection bag being placed on the floor or provide staff interventions to prevent this. Additionally, the care plan lacked instructions for using a catheter secure device to prevent dislodgment or traumatic removal of the catheter. Interviews with staff revealed that the resident's catheter bag was frequently found on the floor, and there was no catheter secure device in place. The Director of Nursing acknowledged that catheter bags should not be on the floor due to the risk of UTIs and expected all residents with catheters to have secure devices. The facility's policy on catheter care emphasized keeping the catheter and drainage bag off the floor but did not address the use of catheter secure devices. Observations and interviews indicated a lack of consistent monitoring and intervention to ensure the resident's catheter care was managed according to best practices.
Failure to Address Dementia-Related Behaviors in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who also had an indwelling urinary catheter. The resident, identified as having severe cognitive impairment, exhibited behaviors such as placing his catheter collection bag on the floor and attempting to hit staff with it. Despite these behaviors, the resident's care plan did not address the management of his indwelling catheter or provide interventions to prevent the catheter bag from being placed on the floor, which could lead to urinary tract infections and other complications. Observations and interviews revealed that the resident frequently placed his catheter bag on the floor and on the nurses' station desk, despite staff attempts to redirect him. The Director of Nursing (DON) acknowledged that the care plan should have addressed the resident's behaviors and the use of a catheter secure device to prevent traumatic removal. However, the care plan inaccurately reflected bladder incontinence instead of addressing the indwelling catheter and associated behaviors. Staff interviews indicated a lack of awareness regarding interventions for the resident's behaviors and the absence of documentation on monitoring the drainage bag. The facility's policy on catheter care emphasized keeping the catheter and tubing off the floor but did not address the use of catheter secure devices. The facility's policy on dementia and behavioral health highlighted the need for individualized, person-centered interventions, but these were not implemented for the resident in question.
Failure to Sanitize Glucometer Between Resident Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not sanitize the common glucometer between blood sugar checks for two residents. This oversight was observed during a survey, where LVN A was seen using the glucometer on Resident #22 and then on Resident #32 without cleaning it in between uses. This failure to sanitize the glucometer could potentially lead to contamination and the spread of blood-borne diseases among residents. Resident #22, a cognitively intact male with Diabetes Mellitus Type II and a history of sepsis due to Methicillin Susceptible Staphylococcus Aureus, was subjected to a finger stick blood sugar test without the glucometer being sanitized. Similarly, Resident #32, who has severe cognitive impairment and Diabetes Mellitus Type II, also underwent a blood sugar test with the same unsanitized glucometer. The facility's policy on infection control mandates the cleaning of resident care equipment to prevent disease transmission, 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 Navasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Creek Healthcare And Rehabilitation Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Accel At College Station | 17.6 mi | ★★★★★ | 8 | 1 |
| Fortress Nursing And Rehabilitation | 18.3 mi | ★★★★★ | 3 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 18.9 mi | ★★★★★ | 10 | 3 |
| Legacy Nursing And Rehabilitation | 24 mi | ★★★★★ | 5 | 0 |
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