Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Crescent during CMS and state inspections, most recent first.
A resident with a recent hip fracture, bipolar disorder, and anxiety disorder was allowed out on therapeutic pass but was not permitted to return when she came back after the pass. Staff completed discharge paperwork, packed her belongings, and treated her as discharged even though the facility’s policy stated residents must be allowed to return after therapeutic leave regardless of payment source. The resident said she had nowhere to go, and the record showed conflicting staff accounts about whether she had left AMA or could return.
Improper Perineal Care During Incontinent Care: A CNA provided incontinent care to a dependent female resident without separating the labia or cleaning each side separately. The CNA said she was trained on the correct technique but did not follow it because she thought the labia had already been separated. RN, ADON, DON, and the ADM stated that correct peri care is nursing staff responsibility and that proper technique is needed to prevent infection and cross contamination; the facility policy required separating the labia and cleansing front to back.
Missed Hydroxyurea Doses on Admission: A resident with thrombocytopenia, chronic myeloproliferative disease, and CML did not receive ordered Hydroxyurea on admission. The hospital discharge order called for Hydroxyurea 500 mg every other day, but the med was not entered promptly, pharmacy delivery was delayed, and the MAR showed the first documented dose was not given until several days later. The family member reported the resident missed his chemotherapy med for three days, and staff interviews showed uncertainty about who completed the admission med review and when the order was obtained.
Inaccurate Meal Intake Documentation: A CNA documented that a resident ate most of breakfast even though she later stated the resident did not eat. The CNA did not notify the nurse at the time, and an LVN reported learning of the missed meal only after paramedics had already left. Staff interviews confirmed that inaccurate charting was documenting something that did not happen, and the facility policy required accurate, timely documentation with no false information.
A resident with multiple complex conditions and a sacral pressure injury had an updated wound care order for zinc plus collagen powder written by an NP, but the wound care LVN did not transcribe and initiate this new treatment for several days, continuing the prior calcium alginate regimen instead. The LVN cited system issues and competing obligations, the NP expected the written order to be promptly carried out, and the DON and ADON described shared but unclear responsibilities for ensuring timely transcription of wound care orders. Review of clinical records confirmed the delay between the date the new order was written and the date it was implemented, contrary to facility policy requiring timely transcription of consulting practitioner orders.
A nurse failed to follow infection control protocols while administering IV antibiotics to a resident on enhanced barrier precautions for MRSA, including not wearing a gown or gloves, not performing hand hygiene, and not sanitizing the overbed table before or after the procedure. These actions were observed on video and confirmed by staff interviews, indicating a lapse in required infection prevention measures.
A resident with a Foley catheter was observed without a required leg strap, despite care plans and facility policy mandating its use to prevent catheter pulling or dislodgement. Staff interviews confirmed the omission, and the resident reported that a secure strap was never attached.
Staff did not wear required gowns while providing Foley catheter care and wound dressing changes for a resident with chronic wounds and an indwelling catheter, despite clear signage and available PPE. The involved staff acknowledged they were aware of the need for full PPE but failed to comply, resulting in a breach of the facility's infection control protocols.
A resident with upper extremity impairment and requiring total assistance with eating was given hot water for soup by a CNA, who left the room after warning the resident that the water was hot. The resident accidentally spilled the hot water, resulting in severe burns. The care plan lacked interventions for hot liquids, staff did not consistently check liquid temperatures, and there was no clear process or responsibility for monitoring hot liquid safety, leading to the incident.
A resident with cognitive intactness and upper extremity impairment was left unattended with a hot beverage, resulting in second-degree burns to her leg. The incident was not documented in the facility's incident log or reported to the state agency within the required timeframe, despite facility policy and regulatory requirements for immediate reporting of such events.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and oversight, resulting in inadequate protection for residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive their prescribed blood pressure medications according to physician-ordered parameters, and staff failed to document when medications were held or not administered. Nursing staff acknowledged errors in both medication administration and documentation, and facility policy requiring proper documentation was not followed.
A facility failed to notify the ombudsman and ensure a safe discharge for a resident with complex medical conditions. The resident was not properly informed of her rights and options, and the facility did not adequately assist her in exploring alternatives. Staff interviews revealed a lack of awareness about notifying the ombudsman, contributing to the deficiency.
Two residents did not have their prescribed medications properly documented as administered, with multiple medications missing documentation on the MARs and no explanations provided in nursing notes. Staff interviews confirmed that all medication administration should be recorded, and the facility's policy requires this, but it was not followed in these cases.
A resident with multiple medical conditions who required assistance with ADLs was observed with long and dirty fingernails after refusing nail care. The CNA did not report the refusal to the nurse, and required documentation and follow-up were not completed, resulting in a failure to maintain the resident's grooming and hygiene.
The facility failed to conduct PASRR Level 2 evaluations for residents with mental illness, as five residents were incorrectly marked negative for mental illness in their PASRR Level 1 screenings. This oversight could risk residents not receiving necessary care. The facility relied on hospital PASRR information and did not reassess or audit these screenings, leading to the deficiency.
The facility failed to ensure physician orders for oxygen administration for two residents requiring respiratory care. One resident with a tracheostomy and respiratory failure was observed receiving oxygen without an order, and another resident's oxygen tubing and humidifier were not labeled or dated. Staff interviews revealed confusion with a new EMR system and a lack of adherence to procedures, risking respiratory complications.
A facility failed to develop a baseline care plan for a newly admitted resident with rhabdomyolysis, UTI, and bipolar disorder. The care plan did not address the resident's PASRR diagnosis or bipolar disorder, as required by facility policy. Staff interviews confirmed the importance of baseline care plans for guiding care and ensuring coordination, but the admitting nurse did not complete the necessary documentation.
A facility failed to implement a comprehensive care plan for a resident, omitting care for a rectal tube placed prior to documentation. The resident, with multiple serious diagnoses, was at risk due to this oversight. Staff interviews revealed confusion over care plan responsibilities, contributing to the deficiency.
A facility failed to secure a resident's indwelling catheter, as required by their care plan and facility policy, leading to a deficiency. The unsecured catheter posed a risk of trauma and improper drainage. Staff interviews revealed uncertainty about how long the catheter had been unsecured, despite the facility's policy mandating the use of a leg strap.
The facility failed to ensure that the lids of two dumpsters were secured, leaving garbage exposed. The Nutrition Director and staff acknowledged the requirement to keep lids closed, but some staff struggled to do so due to their height. The facility's protocol mandates that dumpster doors remain closed at all times.
A resident with quadriplegia and an indwelling catheter was found without a catheter stabilizer, risking dislodgement and trauma. Observations showed the catheter tube improperly positioned under the resident's leg, contrary to facility policy. Staff acknowledged the oversight, noting the importance of securing the catheter to prevent movement and ensure proper urine drainage.
The facility failed to ensure safe and orderly discharges for five residents, lacking proper care planning and involvement in the process. One resident with significant medical needs was discharged without necessary home health services or medical supplies, and family members were not adequately informed. The facility's actions led to multiple appeals, highlighting a pattern of unethical discharge practices.
A facility failed to create a comprehensive baseline care plan within 48 hours of admission for a resident with multiple health issues, including cerebral infarction and colon cancer. The care plan did not address essential health and safety concerns or involve the interdisciplinary team. Interviews revealed a lack of communication and care planning meetings during the resident's nearly three-month stay, leading to unmet needs and disappointment.
A resident admitted with multiple medical conditions, including wounds on the left foot and sacrum, did not receive timely wound care orders due to the admitting nurse's failure to document the wounds and obtain temporary treatment orders. The resident refused assessments from wound care nurses, contributing to the delay. Facility staff interviews revealed that the deficiency was not identified through the facility's audit process, which should have ensured accuracy and prevented delays in care.
A resident admitted with a sacral wound did not receive timely wound care orders due to a failure in documentation and communication by the admitting nurse. Despite the resident's refusal of assessments, facility policy required obtaining treatment orders at admission, which was not done, leading to a delay in care.
A resident with multiple medical conditions was found with a bruise on his left arm, which was not reported by RN A to the facility's Abuse Coordinator as required. Despite the family's inquiry, RN A did not document or notify the appropriate authorities, believing the bruise was old. The facility's policy mandates immediate reporting of such injuries to initiate an investigation, which was not followed.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple health issues, including unhealed pressure ulcers, within 48 hours of admission. The admitting nurse did not include wound care in the plan, and there was no audit to catch the oversight. Interviews with staff indicated a lack of clear processes to ensure accurate admission procedures, risking inappropriate care for the resident.
A facility failed to implement a comprehensive person-centered care plan for a resident with complex medical needs, including epilepsy, oxygen therapy, and a feeding tube. Despite these needs being identified in the resident's MDS, the care plan lacked focus, goals, or interventions for these areas. Interviews revealed confusion among staff about responsibility for care plan completion and updates, with the DON and ADON expected to ensure accuracy. The oversight could result in the resident not receiving appropriate care.
A resident with terminal cancer experienced a significant change in condition, but the facility failed to notify the physician. Despite staff recognizing the resident's distress, the responsible nurse contacted the wrong NP and did not follow up. The resident was later transported to the hospital by EMS and passed away. The facility's protocol for notifying physicians was not followed, leading to a deficiency.
A resident with terminal cancer experienced a change in condition, including weakness and inability to speak, but the LTC facility staff failed to assess, document, or notify the physician appropriately. Despite low oxygen saturation, no standing order for oxygen was present, and emergency services were not contacted in a timely manner. The resident was eventually taken to the hospital by EMS and passed away two days later.
A resident was discharged from an LTC facility without a comprehensive discharge plan, lacking essential information such as home health services and durable medical equipment. The resident and family were not adequately informed or involved in the discharge planning process, and the facility failed to follow its policies for discharge planning, resulting in a deficiency in transfer and discharge rights.
A resident with Alzheimer's and functional quadriplegia received incontinence care from two CNAs who failed to adhere to proper hand hygiene protocols. CNA JJ did not wash or sanitize her hands between glove changes, contrary to the facility's policy. The DON confirmed the expectation for proper hand hygiene, but CNA JJ admitted to washing hands only after every third glove change, highlighting a lapse in infection control practices.
Failure to Allow Return After Therapeutic Leave and Inadequate Discharge Planning
Penalty
Summary
The facility failed to permit a resident to return after therapeutic leave and failed to develop and implement an effective discharge planning process focused on the resident’s discharge goals. Resident #11 was admitted with diagnoses including a right femur fracture, bipolar disorder, and anxiety disorder. Her baseline care plan listed a goal to discharge to the community with assistance as needed, and her admission assessment showed she was cognitively intact with a BIMS score of 15, had mild depressive symptoms, used a walker and wheelchair, and required partial/moderate assistance with several activities of daily living. The resident had physician orders allowing therapeutic pass with medications, and her admission agreement stated that residents may leave for therapeutic home visits with permission and shall be signed out and back in, with a bedhold policy in place. She also had a nursing home transfer and discharge notice dated 6/12/26 stating she would be discharged for nonpayment effective 7/30/26. Her medical record also showed a recent hospital visit after posterior hip replacement surgery, with instructions to avoid bending the hip more than 90 degrees for the first 6 weeks and a right hip incision noted on the after-visit summary. On 6/30/26, the resident left on pass with a documented plan to return later that day. When she had not returned by early the next morning, staff notified her responsible party and the DON, and a transfer/discharge report was completed showing a discharge date of 6/30/26. Later that day, the resident returned to the facility and stated she had been told she was discharged, that her belongings were packed, and that she had nowhere to go. Staff interviews showed conflicting accounts about whether she had left against medical advice or was allowed to return, while the facility’s therapeutic leave policy stated that residents must be permitted to return after therapeutic leave regardless of payment source and that not permitting return constitutes a discharge. The record also reflected that the resident had lived in a homeless shelter before admission and that the facility discussed discharge because she was not at the facility at midnight and had an outstanding balance.
Improper Perineal Care During Incontinent Care
Penalty
Summary
Incontinent care was not provided in accordance with the facility’s perineal care practices for a female resident who was admitted with cardiomyopathy, muscle weakness, and gait and mobility abnormalities, and who was coded as totally dependent on staff for perineal and personal hygiene. Her care plan identified bladder incontinence and directed staff to clean the peri-area with each incontinence episode and monitor for possible causes of incontinence bladder infection. During an observation, a CNA provided incontinent care but did not separate the resident’s labia and did not clean either side of the labia separately. During interview, the CNA stated she had been trained to wipe both sides of the labia, discard the wipes, and then wipe the middle of the labia with a clean wipe, but said she did not follow the proper steps because she thought she had already separated the labia. RN, ADON, DON, and the ADM all stated that peri care was the responsibility of nursing staff and that correct technique was needed to prevent infection, cross contamination, and skin breakdown. The facility policy on perineal care stated to separate the resident’s labia with one hand and cleanse the perineum with the other hand by wiping from front to back.
Missed Hydroxyurea Doses on Admission
Penalty
Summary
The facility failed to ensure that a resident with thrombocytopenia, chronic myeloproliferative disease, and chronic myeloid leukemia received Hydroxyurea as ordered upon admission. The resident was admitted with a hospital discharge instruction to start Hydroxyurea 500 mg, 1 capsule by mouth every other day, beginning on 4/24/26. A physician progress note on 4/24/26 documented that the resident was taking Hydroxyurea 500 mg once daily and stated that the medication list was reviewed and reconciled with the patient. The resident’s medication order was not entered into the facility’s order summary until 4/27/26, when a physician order for Hydroxyurea 500 mg every 48 hours was documented. That same evening, an RN documented that the oncologist called with the order, noted the order was already in place, and recorded that pharmacy was called to deliver the medication. The RN also documented that the resident’s family member said she could go to her pharmacy to get the medication, then later documented that the pharmacy reported the Hydroxyurea would be delivered that night and that the family member could not obtain it from the pharmacy. The MAR showed the resident received Hydroxyurea 500 mg by mouth on 4/29/26, and documentation indicated the medication was not administered on 4/27/26. In a telephone interview, the family member stated the resident missed his chemotherapy medication for three days while in the facility and that they gave him the medication after bringing the issue to staff’s attention. Interviews with nursing and administrative staff indicated uncertainty about who completed the medication review on admission and that the facility expected family members to bring chemotherapy medications from home, with the medication not being ordered from the pharmacy until after the oncologist was contacted.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices by incorrectly documenting the meal percentage intake for one resident. The resident was admitted with diagnoses including high blood pressure, hyperlipidemia, generalized body weakness, and abnormality of gait and mobility. Her admission MDS showed the BIMS score was uncoded because the assessment was not completed on day two of admission. Record review and staff interviews showed that CNA A documented the resident as eating 76 to 100 percent of breakfast, but later stated the resident did not eat breakfast. CNA A said she did not notify the nurse that the resident did not eat. LVN A stated CNA A told her the resident did not eat breakfast only after paramedics had already left the building. RN A, RN B, LVN B, the ADON, and the DON all described inaccurate documentation as recording something that did not happen or was not true, and stated that if a resident did not eat, the CNA was expected to notify the nurse so the resident could be assessed. The DON stated CNA A documented that the resident ate 65 to 100 percent because the resident always ate well. CNA A's time sheet showed this was the first time she had ever worked with the resident. The facility policy stated that each resident's medical record must contain an accurate representation of the resident's actual experiences, documentation must be completed at the time of service or no later than the shift in which the care occurred, and false information shall not be documented.
Delayed Transcription and Implementation of Updated Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly female with multiple complex diagnoses, including hypoxic encephalopathy, cerebral infarction, emphysema, acute respiratory failure with hypoxia, pulmonary edema, type 2 diabetes mellitus, morbid obesity, dysphagia, hemiplegia and hemiparesis, seizures, intracranial hemorrhage, anemia, elevated white blood cell count, myocardial infarction, heart failure, pneumonitis due to aspiration, rhabdomyolysis, hyponatremia, gastrostomy, and hypothermia. Her admission MDS showed severely impaired cognition with a BIMS score of 3, dependence in toileting and personal hygiene, and functional impairments in upper and lower extremities. She was initially identified as having no pressure ulcers but at risk for development, and was care planned for pressure ulcer prevention with interventions such as barrier cream, turning and repositioning every two hours and as needed, and use of suspension devices to reduce pressure on heels and bony prominences. Subsequently, a clinically unavoidable pressure injury form dated 01/25/26 documented a stage 2 coccyx blister. On 01/28/26, a wound treatment order was in place for the sacral area using calcium alginate with TRIAD cream, to be applied daily. On 01/29/26, the Wound Care Specialist NP assessed the sacral wound, identified as a sacral pressure injury, and issued a new written order for zinc plus collagen powder as the wound treatment. This new order was intended to be transcribed and carried out by facility staff. However, review of the resident’s February MAR and TAR showed that the zinc plus collagen powder order was not initiated until 02/04/26, and the completed order summary reflected that the calcium alginate order was not discontinued and the new collagen with TRIAD order not started until 02/03/26, indicating a delay in implementing the updated wound care regimen. Interviews clarified the actions and inactions leading to the delay. The wound care LVN stated he discovered the sacral redness on 01/28/26, notified the family and NP, and received the initial calcium alginate order. He reported that the new wound care order from 01/29/26 was not transcribed the same day, citing internet issues and other obligations such as calling families about new orders, and acknowledged he did not see the new order until 02/03/26. The Wound Care Specialist NP confirmed she provided the zinc plus collagen powder order on 01/29/26 and expected it to be transcribed and implemented, and was unaware it had not been started until 02/04/26. The DON stated that the LVN was responsible for transcribing treatment orders and that the ADON shared an office with him and was responsible for ensuring all orders, including wound care orders, were transcribed in a timely manner, while the ADON reported she was not aware the new wound care orders had not been transcribed and that overseeing wound care orders had not been specifically assigned to her. Facility policies required that consulting practitioner orders be noted and transcribed to the medication or treatment administration record in a timely manner, which did not occur in this case.
Failure to Follow Infection Control Protocols During IV Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow infection prevention and control protocols while administering intravenous (IV) antibiotics to a resident. The resident had a history of osteomyelitis in the left foot and ankle, Type 2 diabetes, muscle weakness, and was on enhanced barrier precautions (EBP) due to wounds and a feeding tube. The care plan also indicated the resident required isolation for MRSA in a wound, with interventions specifying hand washing and the use of protective equipment. On the observed occasion, the LVN entered the resident's room wearing only a mask, without donning a gown or gloves, and did not sanitize or wash hands upon entry. The LVN proceeded to hang the IV medication, handled supplies, and used the overbed table without sanitizing it before or after the procedure. The LVN also failed to wash hands upon exiting the room. These actions were captured on video and confirmed through interviews with facility staff, who stated that proper protocol required hand hygiene, use of gown and gloves, and sanitizing surfaces before and after procedures involving IV medications. Facility policies reviewed included requirements for enhanced barrier precautions and infection control, but the intravenous therapy policy did not specifically address infection control guidelines. Staff interviews confirmed that the observed practices did not align with facility expectations or infection control standards, placing the resident at risk for infection and cross-contamination.
Failure to Secure Foley Catheter with Leg Strap
Penalty
Summary
A resident with a history of paraplegia, neuromuscular bladder dysfunction, and other significant medical conditions was admitted and care planned for a Foley catheter. The care plan included monitoring for pain or discomfort due to the catheter and checking the tubing for kinks each shift. Physician orders specified the use of a Foley catheter, and facility policy required that the catheter be secured with a leg strap to reduce friction and movement at the insertion site. During observation of catheter care, it was noted that the resident did not have a Foley catheter leg strap in place. Interviews with nursing staff confirmed that the resident was supposed to have a secure leg strap to prevent pulling or dislodgement of the catheter, but the strap was not present. The resident reported that staff never attached a secure strap to the catheter tubing. Facility policy and staff interviews confirmed the expectation that all residents with Foley catheters should have a leg strap to prevent dislodgement.
Failure to Use Required PPE During High-Risk Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols for a resident with significant medical needs, including chronic wounds and an indwelling Foley catheter. During direct care activities, including Foley catheter care and wound dressing changes, the Assistant Director of Nursing (ADON), a Certified Nursing Assistant (CNA), and a Registered Nurse (RN) entered the resident's room without donning the required disposable gowns, despite clear signage and the availability of personal protective equipment (PPE) at the entrance. All three staff members only wore gloves while providing care, contrary to the facility's Enhanced Barrier Precautions policy, which mandates both gowns and gloves for high-contact care activities involving residents with wounds or indwelling devices. The resident involved had a complex medical history, including paraplegia, chronic wounds to the sacrum and right lower ischium, an intraspinal abscess, osteomyelitis, and an indwelling Foley catheter. The care plan and physician orders specified the need for enhanced infection control measures, and the resident's room was clearly marked with instructions for staff to use gowns and gloves. Observations confirmed that the required PPE was available outside the room, and the staff acknowledged during interviews that they were aware of the need for full PPE but failed to comply due to distraction or forgetfulness. Facility policy, as well as the revised Enhanced Barrier Precautions guidelines, require the use of gowns and gloves during high-contact care for residents with chronic wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. The staff's failure to adhere to these protocols was confirmed through observation, interviews, and record review, and was acknowledged by the Director of Nursing as a breach of infection control standards.
Failure to Prevent Resident Burns Due to Inadequate Hot Liquid Safety and Supervision
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but had upper extremity impairment and required total staff assistance with eating, was provided with hot water for soup by a CNA. The CNA obtained the hot water from a dispenser in the coffee room, which was later measured to be 167.6 degrees Fahrenheit. The CNA informed the resident that the water was hot and left the room. While the CNA was away, the resident accidentally spilled the hot water on her leg, resulting in second and third degree burns. The incident was reported to the LVN, who assessed the resident and initiated treatment, but the resident was not sent to the emergency room despite her request and the severity of the burns. The resident's care plan did not include interventions or precautions related to being served hot liquids, despite her need for total assistance with eating and her physical impairment. Staff interviews revealed inconsistent practices regarding the testing of hot liquid temperatures before serving to residents, and there was no clear process or designated responsibility for ensuring the safety of hot liquids dispensed from the coffee machine. Some staff relied on subjective methods, such as touching the outside of the cup, and there was no thermometer available for checking temperatures. Additionally, the facility's incident log did not reflect the burn incident, and staff were not uniformly aware of protocols for hot liquid safety. Observations confirmed that the hot water dispenser was accessible to all residents, and there was a lack of oversight or monitoring of the area. Interviews with facility leadership, including the DON and Nutritional Director, indicated uncertainty about who was responsible for monitoring hot liquid temperatures and ensuring resident safety in the coffee room. The facility's policy required immediate reporting and documentation of accidents, but this was not followed in the case of the burn incident. These actions and inactions led to a situation where a resident suffered significant burns due to inadequate supervision and lack of safety measures regarding hot liquids.
Failure to Timely Report Resident Burn Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported within the required timeframes to the administrator and State Survey Agency. Specifically, an incident occurred in which a cognitively intact female resident with multiple medical conditions, including anxiety disorder, rheumatoid arthritis, muscle wasting, hypertension, and heart failure, was left unattended with a hot cup of liquid. This resulted in the resident sustaining second-degree burns to her right leg and experiencing pain. The incident was not documented in the facility's incident log, nor was it reported to the state agency as required. Record reviews revealed that the resident required total staff assistance with eating and had upper extremity impairment, yet was left alone with a hot beverage. After the incident, the resident was found in pain with a burn to her leg, and treatment was provided, including medication and wound care. However, the incident was not reported to Health and Human Services within the mandated 24-hour period, and there was no evidence of timely notification to the appropriate authorities. Interviews with staff indicated a lack of recall regarding the specifics of the incident and uncertainty about reporting responsibilities. Further interviews with facility leadership confirmed that the incident was not reported as required, with the current administrator and DON stating that the event occurred prior to their tenure and acknowledging the potential for additional harm due to the lack of reporting. Review of facility policies confirmed the requirement for immediate reporting of such incidents, but these protocols were not followed in this case.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and interviews, which revealed gaps in staff training and oversight related to the prevention of abuse, neglect, and theft. The lack of clear and enforced procedures contributed to an environment where residents were not adequately protected from potential harm.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Accurately Administer and Document Medications with Parameters
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as ordered by physicians for two residents. For one resident with multiple diagnoses including hypertension, muscle weakness, and severe cognitive impairment, the prescribed blood pressure medication, metoprolol, was not documented as held when the resident's blood pressure was below the physician-ordered parameters. There was no documentation in the nurse's progress notes explaining why the medication was not held, and the responsible RN acknowledged that the medication should have been held and properly documented on the MAR and in the nurse's notes. Another resident, with diagnoses such as essential hypertension, heart failure, and cognitive awareness, had physician orders for both midodrine and metoprolol with specific blood pressure parameters for administration. The MAR indicated that midodrine was not held on several occasions when the resident's systolic blood pressure exceeded the ordered threshold, and metoprolol was not held when the blood pressure was below the required parameters. There was no documentation in the nurse's notes to explain why these medications were administered or not held as per the orders. The RN involved admitted to documenting in error and not following the required procedure for medications with parameters. Interviews with nursing staff and the DON confirmed that medications with parameters must be administered according to the physician's orders and that any medication held or not given should be clearly documented with the reason. The facility's policy also requires that withheld medications be properly documented on the MAR. The lack of adherence to these procedures resulted in the failure to ensure accurate medication administration and documentation for the residents involved.
Failure to Notify Ombudsman and Ensure Safe Discharge
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had a range of complex medical conditions including myasthenia gravis, diabetes, and chronic heart failure, was not properly informed of her rights and options regarding her discharge. The facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's transfer or discharge, which is a requirement to ensure residents have an advocate to inform them of their rights and options. The resident was informed that her Medicare coverage for skilled nursing facility services would end, and she expressed a desire not to remain in long-term care due to financial concerns. Despite this, the facility did not adequately assist her in exploring alternative options or ensure she was fully prepared for the transition. The resident was eventually discharged to an assisted living facility, but the process lacked proper documentation and communication with necessary parties, including the ombudsman. Interviews with facility staff revealed a lack of awareness and understanding of the requirement to notify the ombudsman, which contributed to the deficiency. The Business Manager admitted to not knowing that the ombudsman needed to be informed, and the Executive Director acknowledged the need for staff training on the proper transfer and discharge process. This oversight placed the resident at risk of an unsafe transfer and discharge, as she was not provided with the necessary support and advocacy during the transition.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for two residents. For one resident, who had multiple complex diagnoses including hyperthyroidism, dementia, depression, pain, insomnia, hypotension, and quadriplegia, there were multiple instances where prescribed medications such as levothyroxine, midodrine, melatonin, sertraline, ascorbic acid, ciprofloxacin, gabapentin, and doxycycline were not documented as administered on several days. There was no documentation in the medication administration records (MARs) or nurse's progress notes to indicate whether the medications were given, withheld, or refused, nor any explanation for the omissions. A confidential interview also revealed that the resident had to request her thyroid medication, suggesting lapses in routine medication administration. Another resident, with diagnoses including hypertension, diabetes, depression, hyperlipidemia, peripheral vascular disease, GERD, insomnia, and Alzheimer's disease, also had multiple medications not documented as given on several days. These included furosemide, atorvastatin, melatonin, omeprazole, ascorbic acid, and gabapentin. The MARs showed numerous blanks, and there was no documentation in the nurse's progress notes to explain the missing entries or to indicate if the resident had refused the medications. Interviews with facility staff, including the unit manager, RN, DON, and LVN, confirmed that medications should be documented as given or not given, with reasons for any omissions. Staff acknowledged that blanks on the MARs make it impossible to determine if medications were administered, which could result in residents being overmedicated or not receiving their medications. The facility's policy requires that all physician orders, including medications, be maintained and documented per regulations, but this was not followed in these cases.
Failure to Provide and Document Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain good grooming and personal hygiene for a resident who was unable to perform activities of daily living independently. Specifically, the resident, who had diagnoses including hypertension, hyperlipidemia, muscle weakness, renal insufficiency, dementia, and anxiety, required supervision or assistance for most ADLs. On the date of observation, the resident was found in bed with long and dirty fingernails. The resident had received a bed bath that morning and refused nail care, which was documented on the ADL shower sheet. However, the section for the charge nurse's assessment and intervention was left blank. Interviews revealed that the CNA who provided care did not clean the resident's nails because the resident refused, and the CNA did not report this refusal to the nurse as required by facility policy. The DON confirmed that nail care is the responsibility of both CNAs and nurses, and that refusals of care should be reported to the nurse for follow-up. The facility's policy states that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and hygiene, with refusals documented and communicated appropriately. The failure to ensure the resident's nails were cleaned and trimmed, and the lack of communication and documentation regarding the refusal, led to the deficiency.
Failure to Conduct PASRR Level 2 Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level 1 residents with mental illness received a PASRR Level 2 evaluation. This deficiency was identified for five residents who were reviewed for assessments. These residents were not correctly identified as having mental illness in their PASRR Level 1 screenings, which could place them at risk of not receiving the necessary care and services in the appropriate setting. Resident #4, a female with diagnoses including schizophrenia, psychosis, and major depressive disorder, was incorrectly marked as negative for mental illness in her PASRR Level 1 screening. Her care plan indicated verbal behavioral symptoms and interventions to manage these behaviors. Similarly, Resident #5, with diagnoses of anxiety disorder and major depressive disorder, was also marked negative for mental illness in her PASRR Level 1 screening. Her care plan included interventions for anxiety and physical manifestations of anxiety. The facility's process for handling PASRR screenings was flawed, as indicated by interviews with MDS Coordinators. They relied on PASRR information from hospitals and did not conduct audits on these screenings. The MDS Coordinators admitted to not reassessing residents who were admitted with other diagnoses or if the PASRR was already completed by the hospital. The facility's policy required all new admissions to be screened for mental disorders, but this was not effectively implemented, leading to the deficiency.
Failure to Ensure Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the lack of physician's orders for oxygen administration prior to providing oxygen. Resident #240, a male with a history of cerebral infarct, pneumonia, and acute and chronic respiratory failure, was observed with an oxygen concentrator set at 5 liters per minute via tracheostomy without a corresponding physician's order. Similarly, Resident #73, a female with diagnoses including osteomyelitis, epilepsy, cardiac arrest, and sepsis, was also receiving oxygen therapy at 5 liters per minute without a physician's order. Additionally, the oxygen tubing and humidifier for Resident #73 were not labeled or dated, which is against the facility's policy. Interviews with staff revealed a lack of clarity and adherence to procedures regarding respiratory care. LVN O mentioned that the respiratory therapist should initiate orders and treatment for tracheostomy residents, but there was confusion due to a new electronic medical record (EMR) system. The respiratory therapist admitted to being unfamiliar with the new EMR system, which led to difficulties in entering orders. LVN C emphasized the importance of having physician orders for tracheostomy care and oxygen therapy, noting that the absence of such orders could lead to respiratory distress. The Director of Nursing (DON) confirmed that all humidifiers should be dated and initialed to prevent infection, and that residents with tracheostomies should have orders for oxygen on admission. The Interim Administrator also stated that physician orders are necessary to ensure proper care. The facility's policy on oxygen administration requires verification of a physician's order before the procedure, highlighting the facility's failure to adhere to its own protocols.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a female with a history of rhabdomyolysis, urinary tract infection, and bipolar disorder, was admitted without a care plan addressing her PASRR diagnosis or her bipolar disorder. This omission was identified during a record review and interviews with facility staff, who acknowledged the importance of baseline care plans in guiding care and ensuring coordination among staff. Interviews with various staff members, including LVNs and the Director of Nursing, revealed that the responsibility for initiating baseline care plans lies with the admitting nurse. However, in this case, the baseline care plan was incomplete, lacking critical information necessary for the resident's care. The facility's policy mandates that a baseline care plan should include initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable. The absence of a comprehensive care plan could lead to staff not knowing how to adequately care for the resident.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not address the care for the resident's rectal tube, which was placed prior to the date it was documented in the care plan. This oversight could potentially place the resident at risk for not receiving appropriate interventions to meet their care needs. The resident, a female with multiple diagnoses including osteomyelitis of the vertebra, epilepsy with status epilepticus, cardiac arrest, and sepsis due to Streptococcus pneumoniae, was admitted to the facility with a stage 4 pressure ulcer and incontinence. Despite these conditions, the comprehensive care plan was not updated to reflect the rectal tube placement until a later date. Interviews with facility staff, including an LVN, the DON, and the MDS Coordinator, revealed a lack of clarity and responsibility regarding the initiation and updating of care plans, which contributed to the deficiency.
Failure to Secure Catheter Leads to Deficiency
Penalty
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 facility did not maintain the catheter stabilizer, which is a strap or secure device attached to the resident's thigh to prevent the catheter tube from moving. This deficiency was observed during a survey when the catheter tube was found unsecured, posing a risk of trauma or improper drainage. The resident involved was an elderly male with a history of bladder dysfunction and a Foley catheter in place. His care plan indicated a risk for increased urinary tract infections and required that the catheter be secured with a leg strap. However, during an observation, the catheter was found unsecured, and staff interviews revealed uncertainty about how long it had been unsecured. The resident did not report any pain, and there was no observed trauma at the time of the survey. Interviews with staff, including an LVN and CNA, confirmed that the catheter should have been secured and that it was their responsibility to ensure this. The Director of Nursing and the Interim Administrator acknowledged the importance of securing the catheter to prevent trauma and ensure proper drainage. The facility's policy, updated in 2019, also required the use of a leg strap to secure the catheter tubing.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the lids of two dumpsters were secured. During an observation and interview, it was noted that both dumpsters had their lids completely open, exposing the garbage. The Nutrition Director acknowledged that the housekeeping, kitchen, and nursing staff used the dumpsters and that the trash had not been taken out that morning. He mentioned that some housekeeping staff struggled to close the lids due to their height, requiring them to use a stick to secure the lids. Interviews with the Nutrition Director and another staff member revealed that all kitchen staff were aware of the requirement to keep dumpster lids closed and were responsible for ensuring this. However, the staff member interviewed did not know the specific risks to residents if the lids were left open. The facility's Dumpster Protocol, dated December 2023, stated that dumpster doors should remain closed at all times and that any staff bringing trash to the dumpster should ensure all doors are closed.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. The resident, a male with quadriplegia, a stage four pressure ulcer, and neuromuscular dysfunction of the bladder, was observed without a catheter stabilizer in place. This stabilizer is crucial for preventing the catheter from moving, which could lead to accidental dislodgement and trauma to the bladder and urethra. During observations, it was noted that the catheter tube was not secured to the resident's thigh and was positioned incorrectly, running under the resident's leg. Multiple staff members, including LVNs and CNAs, acknowledged the absence of the catheter strap and the improper positioning of the catheter tube. They confirmed that the facility's policy required the catheter to be secured to prevent movement and ensure proper urine drainage. Interviews with the staff, including the RN DON and the Administrator, revealed that the facility's policy was not followed, as the catheter was not secured. The staff members were aware of the risks associated with unsecured catheters, such as potential trauma and interference with urine flow, yet the deficiency occurred. The facility's urinary catheter care policy emphasized the importance of securing the catheter to prevent infections and ensure unobstructed urine flow.
Failure to Ensure Safe and Orderly Discharge of Residents
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the safe and orderly transfer or discharge of five residents. The facility did not arrange a safe discharge through care planning and failed to involve the residents in the process. Specifically, the facility did not secure a home health agency for one resident prior to discharge, placing the resident at risk of not receiving necessary care and services upon leaving the facility. One resident, who had a history of cerebral infarction, hemiplegia, and colon cancer, was discharged without a proper care plan or involvement in the discharge process. The resident was dependent on staff for various activities of daily living and required assistance with a colostomy bag. Despite these needs, the facility discharged the resident to a group home without home health services or necessary medical supplies, such as extra colostomy bags and a helmet. The resident's family was not adequately informed or involved in the discharge planning, and the resident was transferred without her belongings. Interviews with staff and family members revealed a pattern of unethical discharge practices, including harassment of family members to remove residents due to financial issues. The facility failed to provide required discharge notices and summaries, and there was no evidence of care plan meetings or discharge conferences. The facility's actions led to multiple appeals being filed and won by the residents, indicating a failure to follow regulatory requirements for safe and orderly discharges.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered baseline care plan within 48 hours of admission for a resident, identified as CR#1, who was reviewed for care plans. The baseline care plan did not address the resident's initial goals based on admission orders, physician orders, therapy services, social services, or PASRR recommendations. This omission could place newly admitted residents at risk of not receiving services to meet their needs. The resident, who had diagnoses including cerebral infarction, hemiplegia, and colon cancer, was totally dependent on staff for various activities of daily living and required assistance with positioning and transferring. The report highlights that CR#1's baseline care plan was inadequate, failing to address specific health and safety concerns such as fall risk, supervision needs, and assistance with activities of daily living. Additionally, there was no documentation of a care plan conference with the resident or involvement of the interdisciplinary team. Interviews with family members and the resident revealed that there was no communication or care planning meeting held during the resident's stay, which lasted almost three months. The resident expressed disappointment at not receiving physical therapy or having any interaction with the social worker or other staff members.
Failure to Obtain Timely Wound Care Orders for Resident
Penalty
Summary
The facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. The deficiency involved a resident who was admitted to the facility with multiple medical conditions, including metabolic encephalopathy, peripheral vascular disease, and an amputation above the knee. Upon admission, the resident had wounds on the left foot and sacrum, but the facility did not obtain wound care orders for these areas until several days later. The admitting nurse, RN A, did not document the wounds in the admission progress note or include them in the baseline care plan. Additionally, RN A failed to obtain temporary orders to treat the wounds at the time of admission. The resident refused assessments from wound care nurses on multiple occasions, which contributed to the delay in obtaining treatment orders. However, the facility's policy required that a head-to-toe skin assessment be completed and documented on the day of admission, and that the physician be notified of any identified areas requiring treatment. Interviews with facility staff, including the DON, ADON, and wound care nurses, revealed that the lack of documentation and failure to obtain timely treatment orders were not identified through the facility's audit process. The facility's policy dictated that audits of newly admitted residents should be conducted to ensure accuracy and prevent delays in care, but it was unclear if such an audit was performed for this resident. The delay in obtaining wound care orders could have placed the resident at risk for further injury or complications.
Failure to Obtain Timely Wound Care Orders for Resident
Penalty
Summary
The facility staff failed to ensure that a resident received appropriate wound care upon admission, leading to a deficiency in care. The resident, a male with multiple medical conditions including metabolic encephalopathy and peripheral vascular disease, was admitted with a sacral wound. However, the facility did not obtain wound care orders for this wound from the time of admission until several days later. This lapse in obtaining timely treatment orders was compounded by the resident's refusal to allow wound assessments on multiple occasions. The admitting nurse, RN A, did not document the presence of the sacral wound in the admission progress note or the baseline care plan, nor did she obtain temporary treatment orders for the wound. This oversight was not communicated to the wound care nurses or the subsequent shifts, resulting in a delay in wound care treatment. The facility's policy required a head-to-toe skin assessment and notification of the physician for any identified areas, which was not adhered to in this case. Interviews with facility staff, including the DON, ADON, and wound care nurses, revealed that the lack of documentation and failure to obtain treatment orders were attributed to the resident's refusal of assessments. However, the facility's policy and staff interviews indicated that orders should have been in place regardless of the resident's refusal to prevent delays in care. The deficiency was identified during a review of the resident's medical records and interviews with staff, highlighting a failure in the facility's admission and wound care processes.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation involving a resident, identified as CR#1, who was found with a bruise on his left arm. The bruise was brought to the attention of RN A by the resident's family on 07/04/2024. Despite the family inquiring about the cause of the bruise, RN A did not report the incident to the facility's Abuse Coordinator or document it in the progress notes, as she believed the bruise was old and not indicative of abuse. This inaction was contrary to the facility's policy, which requires immediate reporting of injuries of unknown origin to the appropriate authorities. CR#1 was a male resident with multiple medical conditions, including metabolic encephalopathy, peripheral vascular disease, and chronic diastolic congestive heart failure. He was moderately impaired cognitively, with a BIMS score of 10. On the day the bruise was discovered, CR#1 experienced a change in condition, leading to his transfer to a local hospital where he was diagnosed with pneumonia and COVID-19. The hospital records did not document the bruise, and subsequent observations did not reveal its presence. Interviews with facility staff, including RN A, CNA E, the DON, and the ED, revealed a lack of awareness and communication regarding the bruise. RN A initially acknowledged the family's report of the bruise but later denied any recollection of it. The facility's policy mandates that any injury of unknown origin should be reported immediately to the ED, who serves as the abuse coordinator, to initiate an investigation and report to the State Survey Agency. However, this protocol was not followed, resulting in a failure to ensure the safety and well-being of the resident.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, which is necessary to provide effective and person-centered care. The resident, a male with multiple diagnoses including metabolic encephalopathy, peripheral vascular disease, and unhealed pressure ulcers, was admitted without a baseline care plan addressing his wound care needs. The admitting nurse acknowledged the oversight, stating that the resident was not planned for wounds, and there was no clear process in place to ensure the accuracy of the admission process. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other staff revealed that the baseline care plan should have included skin impairments and that audits should be conducted to ensure accuracy. However, it was unclear if the admission was audited, and the error was not corrected. The facility's policy requires the baseline care plan to include necessary instructions for care, but this was not followed, leading to a risk of inappropriate care for the resident.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident #2, who was reviewed for comprehensive care plans. The resident, a male with multiple complex medical conditions including epilepsy, dysphasia, aphasia, quadriplegia, and others, was admitted to the facility with specific care needs such as oxygen therapy and a feeding tube. Despite these needs being identified in the resident's quarterly MDS, the care plan did not include focus, goals, or interventions to address these critical areas. Interviews with various staff members, including LVNs, RNs, the DON, ADON, and the ED, revealed a lack of clarity and responsibility regarding the completion and updating of comprehensive care plans. The staff indicated that the care plans were supposed to be completed by the DON and ADON, but there was confusion about who was responsible for ensuring their accuracy and completeness. The MDS Nurse could initiate the care plan based on MDS assessments, but the finalization and updates were expected to be done by the DON and ADON. The oversight in Resident #2's care plan was acknowledged by the DON, who admitted that the care plan did not address the resident's seizures, oxygen therapy, and feeding tube needs. This lack of a comprehensive care plan could lead to the resident not receiving appropriate care, as the care plan is essential for guiding clinical nursing staff in providing necessary care. The facility's policies and procedures emphasize the importance of developing and implementing a comprehensive, person-centered care plan for each resident, but this was not adhered to in this case.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment. This deficiency was identified during a review of a case involving a resident with terminal cancer who experienced a change in condition. On the day of the incident, the resident was found to be weak and unable to speak, prompting concerns from both the private nurse and the transporter. Despite these observations, the resident's physician was not notified of the change in condition, and the resident was eventually transported to the hospital by EMS, where he passed away two days later. Interviews with staff revealed that RN B, who was responsible for notifying the physician, mistakenly contacted the wrong nurse practitioner via text message and did not make further attempts to reach the correct physician. The Director of Nursing (DON) was present during the incident but was unaware that the wrong physician had been contacted. The facility's protocol required nurses to notify the physician, family, management, and the DON in case of an unstable resident, but this protocol was not followed. Additionally, the facility's policy did not require documentation of who was contacted or the mode of communication used, which contributed to the oversight. The resident's medical records did not show any orders for oxygen use, and there was no documentation of the physician being notified of the resident's change in condition. The facility's failure to notify the physician and document the change in condition put the resident at risk, as noted by the staff interviews and the facility's own policies. The incident highlighted a breakdown in communication and adherence to established protocols, which ultimately led to the resident not receiving timely medical intervention.
Neglect in Responding to Resident's Change in Condition
Penalty
Summary
The facility failed to ensure the resident's right to be free from neglect, as evidenced by the inadequate response to a change in condition for one resident. The resident, who had terminal cancer and was typically alert and vocal, experienced a significant change in condition, including weakness and inability to speak. Despite these symptoms, the facility staff did not appropriately assess, document, or notify the physician, nor did they provide timely emergency medical treatment. The resident was eventually transported to the hospital by EMS, where he passed away two days later. Interviews with facility staff revealed a lack of clear communication and documentation regarding the resident's condition. RN B, who was not familiar with the resident, failed to document an SBAR or notify the physician of the change in condition. Although the resident's oxygen saturation was low, RN B did not have a standing order for oxygen and relied on PRN orders. The DON and other staff members were present but did not take decisive action to contact emergency services, relying instead on the resident's apparent stability after initial assessments. The facility's documentation and monitoring practices were insufficient, as evidenced by the lack of recorded vital signs and assessments following the initial change in condition. The DON and LVN A did not ensure continuous monitoring or proper documentation of the resident's status. The facility's failure to follow established protocols for notifying physicians and documenting changes in condition contributed to the neglect of the resident's needs, ultimately leading to a delay in receiving necessary medical intervention.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to adequately prepare and document a safe and orderly discharge for a resident, leading to a deficiency in transfer and discharge rights. The resident, who had intact cognition and required various levels of assistance for daily activities, was discharged without a comprehensive discharge plan. The resident's care plan included goals for discharge planning, but there was no evidence of an interdisciplinary team meeting or a developed discharge plan with the resident's involvement. The discharge plan of care provided to the resident was incomplete, lacking essential information such as home health services, durable medical equipment, and necessary contact information. Interviews revealed that the resident and her family were not adequately informed or involved in the discharge planning process. The resident, a former RN, expressed a desire to be informed about the discharge process and potential home health agencies but did not receive the necessary information. The family member also reported concerns about the lack of communication and the incomplete discharge plan. The facility staff, including the social worker and DON, failed to ensure that home health services were arranged prior to discharge, and the resident was discharged with a blank discharge plan document. The facility's failure to follow its policies and procedures for discharge planning was evident in the lack of a 30-day discharge notice, absence of a care plan meeting with the resident, and failure to notify the Ombudsman Office. The social worker admitted to not having a formal meeting with the resident to discuss discharge plans and did not ensure the accuracy and completeness of the discharge plan. The administrator acknowledged the oversight and expressed the need for improved verification of discharge services in the future.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinence care for a resident. The resident, a male with Alzheimer's disease, functional quadriplegia, and gastrostomy status, was dependent on staff for personal hygiene and was always incontinent. During an observation, CNA JJ did not perform hand hygiene before entering the resident's room or before donning clean gloves. She removed the resident's soiled brief and gloves without washing or sanitizing her hands and then donned clean gloves to continue care. CNA JJ admitted to washing her hands only after every third glove change, which contradicts the facility's hand hygiene policy. This policy requires hand hygiene before moving from a contaminated body site to a clean one and after removing gloves. CNA RR, who assisted in the care, acknowledged that CNA JJ should have performed hand hygiene before placing a clean brief on the resident. The Director of Nursing (DON) confirmed that staff are expected to perform proper hand hygiene to prevent infection. The facility's infection control policy mandates a system for preventing and controlling infections, which includes staff training. However, CNA JJ could not recall recent training at this facility, despite having signed an in-service training report on infection control. The DON stated that staff receive regular training and competency checks, but the observed failure in hand hygiene practices indicates a lapse in adherence to these protocols.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 671 citations issued within 25 miles in the last 12 months — including the 56 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sugar Land
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sugar Land Health Care Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Resort Sugar Land, Llc | 1.9 mi | ★★★★★ | 7 | 0 |
| Paradigm At First Colony | 3.9 mi | ★★★★★ | 8 | 0 |
| West Houston Rehabilitation And Healthcare Center | 4.7 mi | ★★★★★ | 6 | 0 |
| Park Manor Of Quail Valley | 5.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.