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 Wurzbach Nursing And Rehabilitation during CMS and state inspections, most recent first.
Three residents were found with unsafe equipment, including missing wheelchair armrest pads and a bed with a detached headboard and exposed particle board. Staff, including an LVN and the DON, were unaware of these hazards prior to the survey, and no work orders had been submitted for repairs. The facility lacked a policy on wheelchair maintenance, and staff interviews indicated that reporting and addressing such hazards had been overlooked.
A nurse administered omeprazole incorrectly by opening a capsule labeled 'Do not crush or open' for a resident with a feeding tube, without consulting the physician for an alternative form. Additionally, expired suction catheter kits and trays were found in two medication rooms, and staff failed to remove them as required by facility policy.
Surveyors found that staff failed to date trays of prepared beverages in the refrigerator and bowls of cereal in dry storage, contrary to facility policy and food safety standards. Staff interviews confirmed that all open or prepared items should be labeled with preparation and use-by dates, but this was not done, potentially allowing the use of expired food items.
Staff failed to follow infection control protocols during care for three residents, including not changing gloves or performing hand hygiene between contaminated and clean tasks, and not wearing required personal protective equipment such as gowns during high-contact care activities involving feeding tubes. These lapses occurred despite facility policies and posted guidelines requiring such practices.
A resident with severe cognitive impairment and multiple diagnoses was fed lunch by a staff member who stood over her rather than sitting at eye level, contrary to facility policy and staff training. Interviews confirmed that staff are expected to sit while assisting with feeding to maintain resident dignity.
A resident with severe cognitive impairment and a high risk of falls was found in bed with her call light on the floor and out of reach, despite her care plan requiring it to be accessible at all times. Staff confirmed the call light should have been within reach and acknowledged that its inaccessibility could delay care.
A resident with severe cognitive impairment and multiple medical conditions was not weighed upon re-admission as required by physician order and facility policy. The initial weight was not recorded until several days after re-admission, and the nurse responsible did not follow the established protocol, resulting in inadequate monitoring of the resident's nutritional status.
A resident with dementia, COPD, diabetes, and hypertension who required scheduled nebulizer treatments was found to have her nebulizer mask left uncovered on the nightstand when not in use. Nursing staff confirmed the mask should have been covered to prevent infection, but this was not done, and there was no specific facility policy addressing this practice.
Surveyors found that two insulin pens used by two residents with diabetes were stored in a medication cart without open dates, preventing staff from knowing when the insulin should be discarded. Nursing staff and the ADON confirmed that insulin should be dated upon opening, but this was not done, and there was no facility policy addressing this requirement.
A resident with severe cognitive impairment and multiple medical conditions, including dysphagia and a history of aspiration, was ordered a pureed and thin liquid diet. Facility nurses inaccurately documented that the resident did not require a mechanically altered diet, despite physician orders and direct observation showing otherwise. The ADON confirmed the documentation error and noted the absence of a facility policy on accurate clinical records.
The facility did not ensure that new hires and existing staff completed required trainings, as shown by missing initial and annual training records for several employees. There was no policy specifying required training topics, completion timeframes, or responsibility for oversight, and the facility relied solely on an online system that did not guarantee compliance.
Two staff members, a CNA and an LVN, did not receive required annual communication training as evidenced by a review of personnel records and training logs. The facility relied on an online training system but lacked a formal policy outlining required training topics, completion timeframes, or responsibility for oversight, resulting in missed annual training for these employees.
Two staff members, a CNA and an LVN, did not receive required annual resident rights training due to the facility's lack of a formal policy outlining required training topics, completion timeframes, and responsibility for ensuring completion. Training records and interviews confirmed the absence of documentation for the required training within the past year.
Two employees, a CNA and an LVN, did not receive required annual training on abuse, neglect, exploitation, and dementia care. Review of records and interviews with human resources and the administrator revealed that the facility lacked a policy specifying required training topics, timeframes, and responsibilities, and failed to ensure completion of these trainings.
Two staff members, a CNA and an LVN, did not receive required annual QAPI training due to the facility's lack of a policy specifying required training topics, timeframes, and responsible parties. Personnel records and training logs showed no evidence of completed QAPI training for these employees, and interviews revealed reliance on an online system without adequate oversight.
Two staff members, a CNA and an LVN, did not receive required annual infection control training, as shown by a review of personnel records and training logs. The facility relied on an online training system but lacked a formal policy specifying required training topics, timeframes, or clear responsibility for ensuring completion, resulting in missed annual infection control training for these employees.
Two employees, a CNA and an LVN, did not receive required annual ethics and abuse, neglect, and exploitation training. Review of records showed no evidence of training completion, and interviews revealed the facility lacked a policy specifying required training topics, timeframes, or responsibility for monitoring completion.
A CNA did not receive the required 12 hours of annual in-service training due to the facility's lack of a formal policy on required training topics, timeframes, and responsibilities. The facility relied on an online training system and email notifications, but did not ensure completion or maintain documentation of a policy outlining these requirements.
Two staff members, a CNA and an LVN, did not receive required annual behavioral health and abuse, neglect, and exploitation training. Review of records showed no evidence of completed training in the past year, and interviews revealed the facility lacked a policy specifying required training topics, timeframes, or responsibility for ensuring completion.
A facility did not immediately notify law enforcement after an allegation of sexual abuse was made involving a resident with severe cognitive impairment. Although the incident was reported to state health authorities and the resident was sent to the ER for assessment, law enforcement was only contacted after a surveyor's inquiry, contrary to regulatory requirements for immediate reporting.
Two residents experienced harm due to inadequate supervision and failure to follow safety protocols. One resident with severe cognitive impairment eloped from the facility after being let out by a visitor, despite being assessed as at risk to wander. Another resident, also with severe cognitive impairment and dependent for transfers, was injured when a CNA transferred her without a hoyer lift or assistance, resulting in the removal of her toenail. Both incidents were confirmed through record review and staff interviews.
Two residents with significant medical needs did not receive their prescribed pain medications due to the facility's failure to secure and account for controlled substances, resulting in the loss and misappropriation of narcotics and other medications. Staff interviews and record reviews confirmed that the medications were missing from the medication carts and were not administered as ordered.
The facility did not report an incident in which one resident with severe cognitive impairment struck another resident, also with severe cognitive impairment, on the head. Staff assessed the resident and found no injuries, and the DON and Administrator decided not to report the event to the state survey agency, believing it was unnecessary without serious injury. This action was inconsistent with the facility's policy requiring all abuse allegations to be reported within 2 hours.
Two residents did not receive their prescribed pain medications as ordered due to failures in the facility's pharmaceutical services, including inconsistent acquisition, dispensing, and documentation practices. Staff interviews revealed confusion and lack of accountability in the process for receiving and documenting narcotic deliveries, leading to missing medications and unaddressed pain management needs.
A facility failed to ensure accurate documentation of medication administration times for three residents, leading to discrepancies in the Controlled Substance Administration Record. A medication aide did not accurately record the administration times for scheduled pain and anti-anxiety medications, including Tramadol, Tylenol with Codeine, and Diazepam. The residents involved had various medical conditions, including cognitive impairments and chronic disorders. The Director of Nursing noted the importance of accurate documentation and acknowledged that the aide had not been trained on the proper procedure.
The facility failed to document wound care and skin treatments for five residents, leading to a deficiency. A resident's diabetic ulcer treatment was not documented on five occasions, while another resident's fungal rash treatment was missed six times. A third resident's multiple wounds were not documented thirty-four times. Two hospice residents also had undocumented treatments. Interviews revealed inconsistencies in the Treatment Administration Record (TAR) and progress notes, contributing to the deficiency.
A resident with a history of vascular disease and diabetes experienced a worsening wound on her foot, but the facility failed to notify her physician in a timely manner. Despite the resident's complaints and signs of deterioration, the physician was only informed during a scheduled visit, leading to a delay in treatment. The facility's policies for immediate notification were not followed, resulting in a communication lapse.
A resident with dementia and schizoaffective disorder experienced a significant change in health status, including high blood pressure and vomiting. Despite receiving new medical orders, the facility failed to notify the resident's representative, leaving them unaware of the resident's condition until a later visit. This oversight violated the facility's policy requiring prompt notification of significant health changes.
A resident with severe cognitive impairment and Huntington's disease was administered Midodrine multiple times outside of physician parameters, despite facility protocols requiring vital sign checks and error reporting.
The facility failed to date five insulin pens when opened, affecting four residents with various diagnoses, including dementia and diabetes. This lapse was observed during a medication cart inspection, despite staff training and facility policies requiring the dating of multi-dose containers.
The facility failed to develop and implement policies to prevent abuse, neglect, and exploitation of residents. Specifically, a CNA did not have a current EMR/NAR check, with the last check conducted over a year ago. The Administrator was unable to provide evidence of a current check, violating the facility's policy to conduct background checks and not employ individuals with findings of abuse, neglect, or exploitation.
The facility failed to report an incident where a resident with severe cognitive impairment had an unwitnessed fall, resulting in a skin tear and a hematoma. Staff provided inconsistent accounts of the incident, and the facility did not follow its policy on timely reporting to the State Survey Agency.
A facility failed to thoroughly investigate a resident's fall, resulting in inconsistent and incomplete documentation. The resident, who had severe cognitive impairment, was found on the floor with injuries, and conflicting information was provided about whether the fall was witnessed. The facility did not adhere to its policy on investigating incidents, placing residents at risk.
The facility failed to provide a written bed-hold policy to a resident before transferring them to a hospital, contrary to their stated procedures. Staff interviews confirmed that bed-hold agreements were not routinely given, despite the facility's policy requiring them.
A resident with multiple diagnoses was discharged to a hospital without a completed discharge MDS. The facility's RN/MDS and LVN staff confirmed the oversight, which violated the facility's discharge process policy and MDS RAI 3.0 guidelines.
The facility failed to complete a discharge summary for a resident with multiple diagnoses, including Alzheimer's disease and heart failure, at the time of a planned discharge. The necessary documentation, including a discharge MDS and a discharge summary report, was not completed, and the DON was unable to provide the discharge summary before the survey exit.
A resident with COPD and other health issues was observed using oxygen without a physician's order. Interviews with staff confirmed that the order was missed and should have been entered on the day of admission, violating the facility's policy on oxygen administration.
The facility failed to administer prescribed Tylenol Extra Strength and Senexon-S to a resident with dementia, diabetes II, chronic pain, and osteoporosis on specific dates. Discrepancies were found in the availability of the medications and communication about their stock status, contrary to the facility's policy on safe and timely medication administration.
A facility failed to maintain effective infection control during wound care for a resident with multiple ulcers and an infection. LVN B did not change gloves after removing a soiled dressing, failed to wash hands or use ABHR between glove changes, and did not wear a gown as required. Despite training, these lapses were confirmed by the DON and infection preventionist nurse.
The facility failed to ensure call light accessibility for three residents, all of whom were high fall risks. One resident's call light was clipped to a privacy curtain, another's was found under a roommate's bed and on the floor, and the third's was under the foot of her bed. Staff interviews confirmed that call lights should be within reach, as per facility policy.
The facility failed to accommodate the food preferences and allergies of two residents. One resident with documented allergies was repeatedly served allergenic foods, while another resident received foods he disliked. Staff admitted to oversight despite having protocols and training in place.
Failure to Maintain Resident Equipment and Environment Free of Hazards
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents, as evidenced by observations of resident equipment and furniture in disrepair. Two residents were found sitting in wheelchairs with missing right armrest pads, exposing bare metal bars with holes where bolts would be attached. These deficiencies were observed during routine checks, and at the time of observation, there were no visible injuries to the residents' arms. Staff, including an LVN and the DON, were unaware of the missing armrest pads prior to being informed during the survey, and acknowledged that the absence of the pads could lead to skin tears. Another resident was found with a detached headboard and a footboard with missing veneer, exposing rough, raw particle board on his bed. The resident expressed concern about the headboard knocking against the wall and the potential for scraping his leg on the exposed particle board. Staff interviews revealed that the condition of the bed had not been reported or addressed, and the DON confirmed that the bed should be maintained to prevent harm. The Maintenance Director was also unaware of the issue until it was brought to his attention during the survey. Record reviews indicated that there was no facility policy on wheelchair maintenance, and work orders for the missing armrest pads and the bed repairs were not found in the facility's work order records for the relevant period. Staff interviews further revealed that although staff were trained to report broken equipment or furniture, these specific deficiencies had not been reported or had been overlooked, resulting in the continued presence of hazards in the residents' environment.
Failure to Follow Pharmaceutical Procedures and Remove Expired Supplies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for residents. Specifically, a nurse administered omeprazole delayed release 20 mg to a resident with a gastrostomy tube by opening the capsule and mixing it with water, despite the medication label clearly stating, "Do not crush or do not open! Should swallow whole." The nurse admitted to not reading the label and acknowledged that the medication should not have been opened, and that the physician should have been contacted to request a liquid form suitable for tube administration. The resident involved was a female with multiple complex diagnoses, including multiple sclerosis, dementia, chronic obstructive pulmonary disease, dysphagia, and GERD, and was dependent on a feeding tube for nutrition and medication administration. Additionally, the facility failed to ensure that expired medical supplies were removed from medication rooms. During observations, one box of suction catheter kit expired on 06/07/2025 was found in the A-wing medication room, and one box of suction catheter tray expired on 07/28/2024 was found in the C-wing medication room. The regional RN acknowledged the presence of these expired items and stated that nurses should have discarded them according to facility policy. Although there were no residents currently requiring suction, the expired supplies remained accessible in the medication rooms. Facility policy required staff to observe manufacturer medication administration guidelines and to discard expired medications and supplies. However, these procedures were not followed, as evidenced by the improper administration of omeprazole and the failure to remove expired suction supplies from medication rooms.
Failure to Date Prepared Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to properly date two trays of prepared and poured glasses of beverages stored in the walk-in refrigerator, as well as a tray containing six prepared bowls of cereal in the dry storage area. These items were not labeled with the date they were prepared or a use-by date, as required by facility policy and professional food safety standards. During interviews, the Dietary Manager (DM) and another staff member confirmed that all open or prepared items stored in the kitchen's walk-in refrigerator and dry storage should be labeled with both the date prepared and the use-by date, and that staff are responsible for ensuring this is done. Record review of the facility's food storage policy and the FDA Food Code confirmed the requirement for date marking of ready-to-eat, time/temperature control for safety foods. The lack of date labeling on these food items could result in the use of old or expired products, as acknowledged by staff during interviews. No specific residents or patient medical histories were mentioned in the report, and the deficiency was identified through direct observation and staff interviews.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three residents, as observed during care activities. In one instance, a certified nursing assistant (CNA) provided incontinent care to a resident with a history of Alzheimer's disease, dementia, and a recent urinary tract infection. The CNA did not remove gloves or perform hand hygiene after cleaning the resident's buttocks and before applying a clean brief, despite being trained and aware of the correct procedure. The facility's policy required glove removal and hand hygiene between contaminated and clean tasks, but this was not followed during the observed care. In another case, a CNA caring for a resident with cerebral palsy, diabetes, and an indwelling urinary catheter failed to change gloves after cleaning the resident's buttocks and before handling a new, clean brief. The CNA admitted to the mistake during an interview, acknowledging that gloves should have been changed and hands sanitized before touching clean items. The facility's policy on perineal care also specified glove removal and hand hygiene before handling clean briefs, but this protocol was not adhered to during the observed care. Additionally, a licensed vocational nurse (LVN) administered medications via gastrostomy tube to a resident with multiple sclerosis, dementia, and a feeding tube, who was under enhanced barrier precautions. The LVN wore gloves but did not don a gown as required by the posted enhanced barrier precaution guidelines, which specifically mandated both gloves and gown for high-contact care activities involving feeding tubes. The LVN acknowledged forgetting to wear the gown, and the assistant director of nursing confirmed that the facility followed these guidelines, even though there was no formal written policy.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a staff member, specifically the Activity Director, failed to treat a resident with dignity during a dining observation. The resident involved was an elderly female with diagnoses including Alzheimer's disease, dementia, major depressive disorder, anxiety, and dysphagia. She was severely cognitively impaired, dependent on staff for all activities of daily living, and required assistance with eating. During the lunch meal, the Activity Director was observed standing over the resident while feeding her, despite the resident's attempts to grab the food tray. Interviews with the Activity Director, DON, and ADON confirmed that facility policy and staff training require staff to sit at eye level with residents when assisting with feeding, as this is considered more dignified and respectful. The Activity Director acknowledged the importance of this practice and admitted to not following it during the observed incident. The facility's policy on resident rights also emphasizes treating all residents with kindness, respect, and dignity.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including atherosclerotic heart disease, peripheral vascular disease, dysphagia, hypertension, and arthritis, was found lying in bed with her call light on the floor and out of reach. The resident's care plan specifically required that the call light be kept within reach due to her high risk of falls and need for assistance with daily activities. Despite this, during an observation, the call light was not accessible to the resident while she was in bed. Interviews with facility staff confirmed that the call light should have been within reach at all times, as per the care plan, and that the resident was capable of using it physically, though she often forgot to do so. Staff were unable to explain why the call light was on the floor and acknowledged that the resident's care could be delayed if she could not access the call light. The facility did not have a specific policy regarding call lights, but their general resident rights policy emphasized treating residents with respect and ensuring access to services.
Failure to Obtain Re-Admission Weight as Ordered
Penalty
Summary
The facility failed to measure a resident's weight upon re-admission as required by both physician order and facility policy. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including pneumonitis due to aspiration, COPD, dysphagia, heart failure, and edema, was re-admitted with a physician order specifying that his weight should be measured upon admission/re-admission and weekly for four weeks. However, review of the resident's records showed that no weight was recorded on the re-admission date, and the first weight measurement was not taken until several days later. The care plan also indicated the need for close monitoring of weight due to the resident's medical conditions and risk factors. Interviews and documentation confirmed that the nurse responsible for the re-admission assessment did not obtain the resident's weight as ordered. The ADON stated that the nurse was an agency nurse who was no longer employed at the facility and could not provide a reason for the omission. Facility policy required weights to be taken at admission, re-admission, and per physician orders, but this protocol was not followed in this instance, resulting in a failure to ensure the resident's nutritional status was adequately monitored at a critical time.
Failure to Properly Store Nebulizer Mask for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency was identified when a resident who required respiratory care was not provided with safe and appropriate handling of respiratory equipment. Specifically, the resident's nebulizer mask was observed on the nightstand uncovered when not in use. Both a licensed vocational nurse and the assistant director of nursing confirmed that the nebulizer mask should have been covered in a plastic bag when not in use to prevent possible infection, but this was not done. The facility did not have a specific policy regarding covering respiratory equipment, but staff acknowledged the expectation to follow standard nursing care practices. The resident involved was an elderly female with multiple diagnoses, including dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertension. She had moderate cognitive impairment and required full assistance with transfers. Physician orders and medication administration records confirmed that she was receiving scheduled nebulizer treatments. The failure to properly store the nebulizer mask was observed during a period when the resident was sleeping, and the mask was not in use.
Insulin Pens Not Dated Upon Opening in Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure all drugs and biologicals were properly labeled and stored according to professional standards for two residents. Specifically, insulin pens for two residents with diabetes were found in a nursing cart without open dates, which is necessary to determine when the insulin should be discarded. Both insulin pens, Lantus Solostar and Novolog Flex Pen, were observed without open dates during a medication cart inspection. For one resident, a male with diagnoses including dementia, type 2 diabetes mellitus, hypokalemia, and heart failure, the insulin Lantus Solostar pen was found without an open date. The resident's medication administration records confirmed regular insulin administration as ordered by the physician. Interviews with nursing staff, including an agency LVN and a regional RN, revealed that the absence of an open date made it unclear when the insulin should be discarded, as the standard is to discard 28 days after opening. The staff were unable to determine if the insulin was still safe for use. Similarly, for a female resident with cerebral atherosclerosis, dementia, type 2 diabetes mellitus, heart failure, and hypertension, a Novolog Flex Pen was found without an open date. The medication administration record showed the resident was receiving insulin as ordered. Interviews with staff confirmed that the insulin should have been dated upon opening, and the lack of an open date prevented staff from knowing when to discard the pen. The ADON acknowledged that nurses are responsible for labeling insulin with open dates, but there was no facility policy in place regarding this practice.
Failure to Accurately Document Mechanically Altered Diet in Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with significant medical needs, including pneumonitis due to aspiration, COPD, dysphagia, heart failure, and edema. The resident, who had severe cognitive impairment and required a mechanically altered diet (pureed food and thin liquids) as ordered by the physician, was incorrectly documented by facility nurses on the Weekly Swallowing/Nutritional Status form. Specifically, the form indicated that the resident had not required a mechanically altered diet in the past seven days, despite clear orders and observations to the contrary. This inaccurate documentation was confirmed through interviews and record reviews, with the ADON acknowledging the error and stating that the resident's medical record should have reflected the actual diet provided. The facility did not have a policy regarding accurate clinical records, and the failure to document the resident's diet correctly could have led to missed treatment and care.
Failure to Ensure Completion of Required Staff Trainings
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members. Specifically, three newly hired employees did not complete required trainings upon hire, as evidenced by a review of their personnel records and training logs. Additionally, two existing staff members did not complete required annual trainings within the previous 12 months. The facility did not have a policy outlining required training topics, timeframes for completion, or clear assignment of responsibility for ensuring trainings were completed. Interviews with the HR representative and the Administrator revealed that the facility relied on an online training system to assign and track trainings, with notifications sent to employees and supervisors. However, there was no formal policy in place to specify training requirements or responsibilities, and the system did not ensure that all staff completed their required trainings. The lack of completed trainings was confirmed through record reviews and acknowledged by facility leadership.
Failure to Ensure Annual Communication Training for Staff
Penalty
Summary
The facility failed to ensure that two employees, a CNA and an LVN, received required annual communication training. Review of personnel records and training logs for both staff members, who were hired in 2020, showed no evidence of completed annual communication training within the previous 12 months. The human resources representative confirmed that the facility uses an online training program to assign and track trainings, and that it is the responsibility of both the employee to complete the training and human resources to ensure completion. However, the system did not ensure that these two staff members completed their required training. Further interviews revealed that the facility did not have a policy specifying required annual training topics, including communication, nor did it outline the timeframes for completion or assign responsibility for ensuring completion. The administrator stated that staff receive email notifications for assigned trainings and are expected to complete them, but there was no formal policy in place to guide or enforce this process. No policy was provided to surveyors prior to exit.
Failure to Provide Annual Resident Rights Training to Staff
Penalty
Summary
The facility failed to ensure that two employees, a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), received annual training on resident rights as required. Review of personnel records and training logs for both staff members, who were hired in 2020, showed no evidence of completed resident rights training within the previous 12 months. The human resources representative confirmed that the facility uses an online training program to assign and track required trainings, and that it is the responsibility of both the employee to complete the training and human resources to ensure completion. However, the system did not ensure that these two staff members completed their annual resident rights training. Further interviews revealed that the facility did not have a policy specifying required annual training topics, timeframes for completion, or clear assignment of responsibility for ensuring completion. The administrator stated that staff receive email notifications for assigned trainings and are expected to complete them, but there was no formal policy in place to guide or enforce this process. The lack of documentation and policy resulted in the failure to provide required annual resident rights training to the identified staff members.
Failure to Ensure Annual Abuse, Neglect, Exploitation, and Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that two employees, a CNA and an LVN, received required annual training on abuse, neglect, exploitation, and dementia care. Review of personnel records and training logs for both employees, who were hired in 2020, showed no evidence that they had completed these trainings in the previous 12 months. The human resources representative confirmed that the facility uses an online training program to assign and track trainings, and that it is the responsibility of both the employee to complete the trainings and human resources to ensure completion. However, the system did not ensure that the required annual trainings were completed for these staff members. Further interviews revealed that the facility did not have a policy specifying required training topics, timeframes for completion, or clear responsibility for ensuring completion. The administrator stated that staff receive email notifications for assigned trainings and are expected to complete them, but there was no formal policy in place. A request for a policy outlining annual training requirements and responsibilities was made but not provided prior to the survey exit.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that two employees, a CNA and an LVN, received annual training on the Quality Assurance and Performance Improvement (QAPI) program as required. Review of personnel records and training logs for both staff members, who were hired in 2020, showed no evidence of QAPI training within the previous 12 months. The human resources representative confirmed that the facility uses an online training system to assign and track trainings, and that it is the responsibility of both the employee to complete and HR to ensure completion of required trainings. However, the system did not ensure that these two staff members completed their annual QAPI training. Further interviews revealed that the facility did not have a policy specifying required annual training topics, including QAPI, nor did it outline the timeframes for completion or assign responsibility for ensuring completion. The administrator and HR representative both indicated reliance on the online system and assumed responsibilities, but no documentation or policy was provided to clarify these requirements. As a result, the facility did not provide the necessary annual QAPI training to the identified staff members.
Failure to Provide and Document Annual Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure that annual infection control training was completed for two employees, a CNA and an LVN, as required by its infection prevention and control program. Review of personnel records and training logs for both employees, who were hired in 2020, showed no evidence of infection control training within the previous 12 months. The human resources representative confirmed that the facility uses an online training system to assign and track trainings, and that it is the responsibility of both the employee to complete the training and human resources to ensure completion. However, the system did not ensure that these two staff members completed their required annual infection control training. Further interviews revealed that the facility did not have a policy specifying required annual training topics, including infection control, nor did it outline the timeframes for completion or assign responsibility for ensuring completion. The administrator stated that staff receive email notifications for assigned trainings and are expected to complete them, but there was no formal policy in place to guide or enforce this process. The lack of documentation and policy contributed to the failure to provide and track required annual infection control training for the identified staff members.
Failure to Ensure Annual Ethics and Abuse Prevention Training for Staff
Penalty
Summary
The facility failed to ensure that two employees, a CNA and an LVN, received required annual ethics training and annual abuse, neglect, and exploitation training. Review of personnel records and training logs for both employees, who were hired in 2020, showed no evidence of completion of these trainings in the previous 12 months. The human resources representative, who was new to the facility, stated that the facility uses an online training program to assign and track trainings, with notifications sent to employees and their supervisors. However, it was revealed that the facility relied solely on this system and did not verify completion of the trainings. Further interviews indicated that there was no facility policy specifying required annual training topics, timeframes for completion, or clear assignment of responsibility for ensuring completion. The administrator assumed that human resources was responsible for monitoring training completion, but no documentation or policy was provided to support this. As a result, the facility did not ensure that all staff received necessary annual training in compliance and ethics, as well as abuse, neglect, and exploitation prevention.
Failure to Ensure Required Annual CNA Training Completed
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) received the required minimum of 12 hours of annual in-service training. Review of personnel records for the CNA showed a hire date of 01/01/2020, and the training log for the previous 12 months indicated that less than the required 12 hours of in-service training had been completed. The human resources representative confirmed that the facility uses an online training program to assign and track trainings, and that it is the responsibility of both the employee to complete the trainings and human resources to ensure completion. However, the system did not ensure that the required annual training was completed for the CNA in question. Further interviews revealed that the facility did not have a policy specifying required training subjects, timeframes for completion, or clear assignment of responsibility for ensuring completion of annual trainings. The administrator stated that staff receive email notifications for assigned trainings and are expected to complete them, but there was no formal policy in place. When requested, the facility was unable to provide a policy outlining annual training topics, required trainings for CNAs, timeframes for completion, or responsible parties prior to the survey exit.
Failure to Ensure Annual Behavioral Health and Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that two employees, a CNA and an LVN, received annual behavioral health training as required. Review of personnel records and training logs for both employees, who were hired in 2020, showed no evidence of behavioral health training completed in the previous 12 months. Additionally, there was no documentation that these employees received annual training on abuse, neglect, and exploitation. The human resources representative confirmed that the facility uses an online training program to assign and track trainings, with responsibility shared between employees and HR to complete and monitor required trainings. However, the system did not ensure completion of the required annual trainings for these staff members. Interviews with the HR representative and the Administrator revealed that the facility did not have a policy specifying required training topics, timeframes for completion, or clear assignment of responsibility for ensuring completion. Both acknowledged reliance on the online system and the expectation that staff would complete assigned trainings, but there was no formal process or policy in place to guarantee compliance. A policy outlining annual training requirements and responsibilities was requested but not provided prior to the survey exit.
Failure to Timely Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was reported to local law enforcement immediately, as required by regulations. The incident involved a female resident with severe cognitive impairment, including dementia and Alzheimer's disease, who required significant assistance with activities of daily living. The resident's responsible party and a family member reported to the facility that a CNA had inappropriately touched the resident during incontinent care. The allegation was made known to the facility administration, and the resident was subsequently sent to the emergency room for assessment, where no definitive findings of sexual abuse were documented, but prophylactic treatment for a possible STD was provided. Despite the serious nature of the allegation and the resident's vulnerability, the facility did not notify law enforcement at the time the allegation was reported. Interviews with facility staff, including the Administrator, DON, and other personnel, revealed a lack of clarity regarding the requirement to contact law enforcement. The Administrator stated that a self-report was made to the state health authority and that internal interventions were initiated, but law enforcement was not contacted until after the surveyor inquired about the matter. The facility's internal investigation file also lacked a law enforcement case number, and staff interviews indicated uncertainty about whether law enforcement had been notified. The facility's policies and state regulations require immediate reporting to law enforcement in cases of alleged abuse, especially when the resident is hospitalized or treated in an emergency room due to the alleged conduct. The delay in notifying law enforcement was confirmed through interviews and record reviews, with the Administrator acknowledging that law enforcement was only contacted after discussions with the surveyor and review of regulatory requirements. This failure to report the allegation to law enforcement in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Unsafe Transfers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In the first incident, a male resident with Alzheimer's disease, chronic kidney disease, and type 2 diabetes, who had a severely impaired cognition (BIMS score of 2), was assessed as ambulatory and at risk to wander but had no documented history of wandering. Despite this, the resident was observed attempting to exit through a fire door and was later found approximately 0.2 miles from the facility after eloping. The investigation determined that the resident likely exited through the front door after being let out by an unknown visitor, and staff interviews confirmed that he had not previously exhibited wandering or elopement behaviors. In the second incident, a female resident with Alzheimer's disease, type 2 diabetes, and heart failure, who was severely cognitively impaired (BIMS score of 0) and dependent on staff for all transfers, was transferred from her bed to her wheelchair by a CNA without the use of a required hoyer lift and without assistance from a second staff member. During this improper transfer, the resident's toenail caught on the floor, resulting in the removal of her entire left great toenail and additional redness to her hips and ribs. The CNA did not report the injury to the nurse, and the family notified the nurse after noticing the injury. Both incidents were identified as past noncompliance, with the facility failing to follow established protocols for monitoring residents at risk of elopement and for safe transfer procedures. The deficiencies were substantiated through record reviews, staff and family interviews, and direct observation, demonstrating lapses in supervision and adherence to care plans that resulted in harm to the residents.
Failure to Secure and Account for Resident Pain Medications
Penalty
Summary
The facility failed to ensure the security and proper management of pain medications for two residents, resulting in the misappropriation and loss of controlled substances. For one resident with a history of osteomyelitis, peripheral vascular disease, diabetes with neuropathy, and chronic foot ulcer, records showed that prescribed HYDROcodone-Acetaminophen was not administered as ordered, and significant quantities of the medication were found missing. The resident's medication administration records indicated inconsistent administration of pain medication, and staff interviews revealed that the medication was not available when requested. Another resident, diagnosed with dementia, bipolar disorder, osteoarthritis, and osteoporosis, also experienced missing pain medications, including HYDROcodone-Acetaminophen and Tramadol. Medication administration records showed that these medications were not given as ordered, and a facility investigation determined that large quantities of narcotics and other controlled substances could not be accounted for. Staff interviews and record reviews confirmed that the medications were not present in the medication carts and had not been administered to the resident as prescribed. The facility's own investigation identified multiple staff members who had access to the medication carts during the period when the drugs went missing. Despite negative drug tests for the staff involved, the missing medications were never recovered. The facility's policy defines misappropriation as the wrongful use or transfer of resident property, and the events described meet this definition, as the residents' medications were not secured and were lost without their consent.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the appropriate authorities, including the State Survey Agency. Specifically, the facility did not report an incident in which one resident struck another resident on the head. Both residents involved had severe cognitive impairments, as indicated by low BIMS scores, and were care planned for behaviors such as physical and verbal aggression. The incident occurred when one resident hit his roommate, who was then assessed and found to have no injuries and expressed a desire to return to sleep. Interviews with staff, including an LVN and the DON, revealed that the incident was not reported to the state survey agency because there was no injury and both residents had low BIMS scores. The DON and Administrator believed that reporting was only necessary if there was a serious injury. However, the facility's own policy required reporting of abuse allegations within 2 hours, regardless of injury. The failure to report the incident was contrary to both regulatory requirements and facility policy.
Failure to Ensure Accurate Acquisition and Dispensing of Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of pain medications as ordered by physicians for two residents. For one resident with a history of osteomyelitis, peripheral vascular disease, diabetes with neuropathy, and chronic foot ulcer, the medication administration records showed inconsistencies in the receipt and administration of prescribed HYDROcodone-Acetaminophen and Tylenol Extra Strength. The resident received only one dose of HYDROcodone-Acetaminophen in February and none in March, despite ongoing orders, and Tylenol was administered only twice in March. Pain assessments were documented, with occasional reports of pain, but the administration of pain medication did not align with the physician's orders. Another resident, diagnosed with dementia, bipolar disorder, osteoarthritis, and osteoporosis, also experienced failures in the acquisition and dispensing of pain medications. The medication administration records indicated that HYDROcodone-Acetaminophen was not administered during the period it was ordered, and Tramadol was only given once in response to a documented pain level. In March, no doses of Tramadol were administered up to the time of the investigation, despite ongoing orders and at least one documented pain episode. Interviews with nursing staff and review of facility policies revealed inconsistent practices regarding the receipt and documentation of narcotic deliveries. Staff described varying procedures for signing delivery manifests, storing documentation, and reconciling narcotic counts. Some staff reported that delivery manifests were shredded or not properly filed, and there was no consistent process to ensure two nurse signatures on narcotic deliveries. The facility's own investigation identified a drug diversion event, with missing narcotic medications for both residents, and acknowledged lapses in accountability and documentation for medication receipt and storage.
Inaccurate Documentation of Medication Administration Times
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate documentation of medication administration times for three residents. Specifically, the medication aide (MA A) did not accurately document the administration times for controlled substances on the Controlled Substance Administration Record. This discrepancy was observed for three residents who were receiving scheduled pain medications, including Tramadol and Tylenol with Codeine, as well as an anti-anxiety medication, Diazepam. Resident #1, who was severely cognitively impaired and diagnosed with metabolic encephalopathy, acute kidney failure, and hypercalcemia, was prescribed Tramadol for pain management. The medication was scheduled to be administered three times a day, but the administration time recorded by MA A did not match the actual time the medication was given. Similar issues were noted for Resident #2, who was also severely cognitively impaired and diagnosed with dementia, cerebral palsy, and osteoarthritis. The administration time for her Tramadol medication was inaccurately documented. Resident #3, who was cognitively intact and diagnosed with anxiety disorder, schizoaffective disorder, and rheumatoid arthritis, was prescribed both Tylenol with Codeine and Diazepam. The administration times for these medications were also inaccurately recorded by MA A. The Director of Nursing (DON) acknowledged the importance of accurate documentation to ensure compliance with medication schedules and noted that MA A had not been trained on the proper procedure for documenting controlled substances. The facility's policy requires accurate documentation of the time of administration for controlled substances, which was not adhered to in these cases.
Deficiency in Documentation of Wound Care and Skin Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five residents, leading to a deficiency in documenting wound care and skin treatments. For Resident #1, wound care was not documented on five occasions, despite having a diabetic ulcer that required daily treatment. Interviews revealed that the resident sometimes refused treatments, and there were inconsistencies in the documentation of wound care in the Treatment Administration Record (TAR) and progress notes. Resident #2's skin treatment was not documented on six occasions, despite having a fungal rash that required treatment every shift. The resident, who was severely cognitively impaired, sometimes refused care, and the lack of documentation in the TAR and progress notes contributed to the deficiency. Similarly, Resident #3's wound care was not documented on thirty-four occasions, with multiple wounds requiring treatment. The resident was severely cognitively impaired, and the TAR and progress notes failed to consistently document the treatments provided. For Resident #4, wound care was not documented on two occasions, and for Resident #5, it was not documented on one occasion. Both residents were on hospice care, with conditions that required regular wound care. Interviews with hospice nurses indicated that the residents received adequate care, but the lack of documentation in the TAR and progress notes led to the deficiency. The facility's policy required all treatments to be documented, but the failure to do so resulted in unclear and inconsistent records.
Failure to Notify Physician of Worsening Wound
Penalty
Summary
The facility failed to immediately inform a resident's physician of a significant change in the resident's physical condition, specifically regarding a worsening wound. The resident, who had a history of peripheral vascular disease, type 2 diabetes mellitus, and atherosclerosis with ulceration, complained of a worsening wound on her right foot. Despite the resident's complaints and the presence of signs indicating deterioration, such as maceration and foul odor, the physician was not notified in a timely manner. The resident's wound was observed to have worsened over the weekend, yet the attending physician and the on-call nurse practitioner were not informed until the physician's scheduled visit on the following Monday. Interviews with staff revealed that the nursing process for changes in wound condition involved notifying the treatment nurse, who would then inform the treatment nurse practitioner. However, this protocol was not followed, leading to a delay in addressing the resident's condition. The facility's policies required immediate notification of the physician for significant changes in a resident's condition, but this was not adhered to in this case. The Director of Nursing and the Administrator acknowledged the lapse in communication, with the Director of Nursing stating that the worsening of the wound over the weekend was not reported to him. The failure to notify the physician promptly could have led to a delay in treatment, as the physician indicated that he would have initiated antibiotics and ordered further tests if informed earlier.
Failure to Notify Resident's Representative of Health Status Change
Penalty
Summary
The facility failed to immediately inform a resident and notify the resident's representative of a significant change in the resident's health status. The resident, who had a history of dementia and schizoaffective disorder, experienced a change in condition characterized by high blood pressure, vomiting, and low oxygen levels. Despite receiving new medical orders for oxygen, anti-high blood pressure medication, and anti-nausea medication, the facility did not report these changes to the resident's representative. The deficiency was identified through interviews and record reviews, which revealed that the LVN responsible for the resident's care documented the change in condition and the new medical orders but did not notify the resident's representative. The LVN acknowledged the oversight, stating that they did not consider reporting the change of condition and new treatments to the resident's family. This lack of communication resulted in the resident's representative being unaware of the resident's health decline until visiting the facility days later. The facility's policy requires prompt notification of the resident, their physician, and their representative in the event of significant changes in the resident's condition. However, this policy was not followed, as evidenced by the failure to inform the resident's representative of the resident's health status and new medical orders. This oversight denied the resident's representative the opportunity to participate in the resident's care plan and make informed decisions regarding their treatment.
Failure to Administer Medication Within Physician Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was administered Midodrine outside of physician parameters. Resident #28, a female with severe cognitive impairment and a diagnosis of Huntington's disease, was prescribed Midodrine for orthostatic hypotension with the instruction to hold the medication if her systolic blood pressure (SBP) was over 120. However, the medication was administered multiple times when her SBP was above this threshold, including instances where her SBP was 124, 122, 128, and 126. Interviews with staff revealed that the expectation was for nurses to take vital signs immediately before administering medications with specific parameters and to notify the physician, DON, and responsible party if a medication error occurred. Despite this protocol, the errors were not reported as required. The facility's policy stated that medications should be administered according to prescriber orders, but this was not followed in the case of Resident #28.
Failure to Date Insulin Pens When Opened
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored properly in the medication cart, specifically failing to date five insulin pens when opened. This deficiency was observed during a medication cart inspection on Station A, where insulin pens for four residents were found without open dates. The residents involved had various diagnoses, including dementia, diabetes, and major depressive disorder, and were receiving insulin injections as part of their treatment plans. The lack of open dates on the insulin pens could result in the administration of expired medications, posing a risk to the residents' health. Resident #4, a female with moderately impaired cognition, had orders for Basaglar and NovoLog insulin pens, which were not dated when opened. Resident #31, a female with severely impaired cognition, had orders for Humulin N insulin pens, which were also not dated. Resident #53, a female with intact cognition, had orders for Lantus insulin pens, which were found without open dates. Resident #82, a male with severely impaired cognition, had orders for insulin glargine pens, which were similarly not dated when opened. Interviews with the ADON, DON, and ADM revealed that all staff had been trained to date insulin pens when opened, and it was the responsibility of the nurses, ADON, and DON to monitor medication carts and ensure medications were dated. The facility's policies on administering medications and medication preparation also required that multi-dose containers be dated when opened. Despite this training and policy, the failure to date the insulin pens was observed, indicating a lapse in adherence to the facility's procedures and protocols.
Failure to Conduct Current EMR/NAR Check for CNA
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, CNA E did not have a current EMR/NAR check. CNA E was hired on 4/21/2024, but the last EMR/NAR check was conducted on 3/17/2023. During an interview on 4/26/2024, the Administrator was unable to provide evidence of a current EMR/NAR check for CNA E before the exit. The facility's policy, dated April 2021, mandates conducting employee background checks and not employing individuals with findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. The failure to have a current EMR/NAR check for CNA E could place residents at risk of abuse, neglect, and exploitation.
Failure to Report Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for one resident reviewed for abuse and neglect. Specifically, the facility did not report an incident in which a resident had an unwitnessed fall, resulting in a skin tear and a hematoma to her head. The resident, who had severe cognitive impairment and was at risk for falls due to dementia and an unsteady gait, was found on the floor holding a napkin to her head, confused and unable to verbalize how she fell. Despite the severity of the incident, the facility did not report it to the State Survey Agency as required by federal regulations. Interviews with staff revealed inconsistencies in the account of the incident, with the Director of Nursing (DON) initially unable to identify a witness and later providing conflicting information about who witnessed the fall. The facility's documentation also showed discrepancies, with different accounts of how the fall occurred and who witnessed it. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not followed, as the incident was not reported within the required timeframes. This failure to report could place residents at risk for abuse and neglect and could lead to a diminished quality of life and psychosocial harm.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who was found on the floor of their room with a skin tear to the right forearm and a hematoma to the top of the scalp. The resident, who had severe cognitive impairment due to Alzheimer's disease, was unable to verbalize how the fall occurred. The initial incident report indicated no witnesses, but subsequent interviews revealed conflicting information about whether the fall was witnessed. The Director of Nursing (DON) was unable to provide a witness statement or a completed investigation report at the time of the surveyor's request, despite stating that the fall was witnessed by a housekeeper and later by the Admissions Coordinator. The DON eventually provided a hand-typed document stating the fall was witnessed by the Admissions Coordinator, but this was not part of the initial documentation. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention requires the identification and investigation of all possible incidents. However, the facility did not adhere to this policy, as evidenced by the incomplete and inconsistent investigation into the resident's fall. The lack of a thorough investigation placed residents at risk of abuse, neglect, exploitation, or mistreatment. Interviews with staff, including the Licensed Vocational Nurse (LVN) and the Administrator, further highlighted the gaps in the facility's investigative process and documentation practices.
Failure to Provide Written Bed-Hold Policy
Penalty
Summary
The facility failed to provide written information to a resident or the resident's representative specifying the duration of the bed-hold policy before the resident was transferred to a hospital. This deficiency was identified for one resident who was transferred to a hospital and returned the following day. The resident, who had intact cognition, did not receive a written bed-hold policy upon transfer, contrary to the facility's stated procedures and policies. Interviews with facility staff revealed that the facility did not routinely provide bed-hold agreements when residents were transferred to the hospital. The Administrative Coordinator and the Administrator both confirmed that the facility held beds for residents without providing written bed-hold agreements. The Business Office Manager also stated that bed-hold agreements were not given, as the facility held the beds until residents returned. This practice was inconsistent with the facility's policy, which required signed bed-hold agreements for residents discharged to the community who wished to return to the same bed. The facility's policy on bed-hold agreements, governed by the Texas Administrative Code, mandates that signed agreements be obtained at the time of discharge. The policy allows for verbal agreements to be documented if the resident or representative cannot sign in person. However, the facility had not adhered to this policy, as evidenced by the lack of bed-hold agreements provided to residents transferred to the hospital. This failure could result in residents not being informed of their rights and the facility's bed-hold policy, potentially leading to improper discharges and unsafe conditions.
Failure to Complete Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure that each resident receives an accurate assessment, specifically for one resident who was discharged without a completed discharge Minimum Data Set (MDS). Resident #77, a female with multiple diagnoses including Alzheimer's disease, heart failure, chronic kidney disease, adult failure to thrive, osteoporosis, and osteoarthritis, was admitted on an unspecified date and discharged to a hospital due to critical lab results. The discharge MDS was not completed within the required timeframe, as confirmed by interviews with the facility's RN/MDS and LVN staff. The RN/MDS acknowledged missing the discharge MDS and stated it should have been done soon after the resident was discharged and it was known they would not return to the facility. The facility's discharge process policy requires communication with staff about upcoming discharges and notification of the MDS nurse. However, this protocol was not followed in the case of Resident #77. The MDS RAI 3.0 guidelines mandate that a discharge MDS must be completed within 14 days after the discharge date and submitted within 14 days after completion. The failure to complete the discharge MDS could result in inaccurate resident information and affect overall resident monitoring and care planning.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure that a discharge summary was completed for a resident at the time of a planned discharge. Specifically, Resident #77, who had diagnoses including Alzheimer's disease, heart failure, chronic kidney disease, adult failure to thrive, osteoporosis, and osteopathic degenerative joint disease, was discharged without a discharge summary. The resident was admitted on an earlier date and was discharged on a later date, but the necessary documentation, including a discharge MDS and a discharge summary report, was not completed. The Director of Nursing (DON) was unable to provide the discharge summary report before the survey exit. The facility's policy on transfer or discharge, dated October 2022, requires documentation of the resident's overall medical, physical, and mental condition, disposition of personal effects, and disposition of medications when a resident is transferred or discharged. However, this policy was not followed in the case of Resident #77. The resident's care plan indicated a wish to remain in long-term care, but the resident was transferred to a hospital due to critical lab results and did not return. This lack of proper documentation could affect all residents and result in inaccurate resident information.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. Resident #240, a male with diagnoses including hypertension, atrial fibrillation, COPD, and falls, was observed using oxygen via an oxygen concentrator at 4 liters per minute through a nasal cannula on multiple occasions. However, a review of the resident's electronic medical record and physician's order listing report revealed that there was no physician's order for the administration of oxygen for this resident. Interviews with the resident, the Director of Nursing (DON), and the Administrator (ADM) confirmed that the resident was admitted with oxygen and that any resident using oxygen must have a physician's order. The DON and ADM acknowledged that the order was missed and should have been entered on the day of admission. The facility's policy on oxygen administration also required verification of a physician's order before administering oxygen. The failure to obtain and document the necessary physician's order for oxygen administration for Resident #240 represents a deficiency in the facility's respiratory care practices.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #64, as evidenced by the non-administration of prescribed medications. Resident #64, who has a medical history including dementia, diabetes II, chronic pain, and osteoporosis, was not administered her Tylenol Extra Strength and Senexon-S on specific dates. The resident's care plan indicated the need for these medications to manage pain and constipation, yet the medications were not given on 4/9/2024 and 4/12/2024 by LVN D. The MAR for April 2024 confirmed the missed doses, and interviews with the DON and LVN D revealed discrepancies in the availability of the medications and communication about their stock status. The DON stated that the medications were available in central supply and could be obtained over the counter, while LVN D claimed the medications were out of stock and not administered. LVN D also mentioned notifying the DON and Administrator about the stock issue, but the Administrator denied any discussion about withheld medications. The facility's policy on administering medications, dated April 2019, mandates that medications be administered in a safe and timely manner as prescribed, which was not adhered to in this case.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of LVN B during wound care for a resident. LVN B did not change gloves after removing a soiled dressing and failed to wash her hands or use alcohol-based hand rub (ABHR) between glove changes. Additionally, LVN B did not wear a gown during the procedure, which is required under the facility's enhanced barrier precautions policy. These lapses in protocol were observed during wound care for a resident with multiple venous and arterial ulcers and an infection of the foot. The resident involved was a male with a history of diabetes, hypertension, heart failure, and Alzheimer's disease, and had severely impaired cognition. The resident's care plan included specific interventions for treating wounds and monitoring for signs of infection. Despite this, LVN B did not adhere to the infection control protocols, which included changing gloves between dirty and clean tasks and wearing appropriate personal protective equipment (PPE). Interviews with LVN B, the Director of Nursing (DON), and the infection preventionist nurse (RN A) confirmed that the staff had been trained on infection control, handwashing, and enhanced barrier precautions. However, LVN B admitted to not following the protocols during the observed wound care. The DON and RN A acknowledged the potential for cross-contamination and the spread of infection due to these lapses in protocol adherence. The facility's policies on handwashing, PPE, and wound care were reviewed and found to be in place, but not followed by LVN B during the incident.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences for three residents regarding the accessibility of their call lights. Resident #3, a [AGE] year-old male with anxiety disorder and epilepsy, was observed with his call light clipped to the privacy curtain at the foot of his bed, out of his reach. Despite being a high fall risk with a history of seizures and poor safety awareness, his care plan specifically required that his call light be within reach. Resident #3 confirmed that he did not place the call light on the privacy curtain and relied on it to call for assistance. Resident #6, a [AGE] year-old female with anxiety disorder, seizures, and schizoaffective disorder, was found twice with her call light out of reach—once under her roommate's bed and another time on the floor beside her bed. She was unaware of the call light's location and stated that staff usually placed it within her reach. Resident #6, who required moderate to maximum assistance with daily activities and was a high fall risk, was observed yelling for help because she could not reach her call light. Resident #8, a [AGE] year-old female with Alzheimer's Disease, was observed with her call light on the floor under the foot of her bed. She was dependent on staff for all activities of daily living and was also a high fall risk. Interviews with staff, including the RN MDS, CNA A, and the DON, confirmed that call lights should be within residents' reach and that it was the responsibility of all staff to ensure this. The facility's policies on fall risk reduction and fall prevention also emphasized the importance of keeping call lights within reach as a strategy to mitigate environmental risk factors.
Failure to Accommodate Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of two residents. Resident #5, who has allergies to chicken, chocolate, oats, and spinach, was repeatedly served foods containing these allergens. Despite the resident's clear communication of her allergies and the documentation on her tray card, she received a chocolate milkshake, which she had to refuse. The LVN responsible for checking the meal trays admitted to missing the allergy information, despite having received training on verifying tray accuracy. Resident #7, who dislikes sweet potatoes/yams and zucchini, was served these items despite his preferences being documented on his tray card. The resident expressed his dissatisfaction and stated he would not eat the disliked items. The RN responsible for verifying the meal trays also admitted to missing the information on the tray card, acknowledging the importance of ensuring residents receive food they like to maintain sufficient food intake. Interviews with the Dietary Manager and the DON revealed that the facility had protocols in place for verifying meal tray accuracy, involving multiple staff members in the process. However, both acknowledged that the errors in serving the residents' meals were oversights. The facility's policy emphasized the importance of honoring resident food preferences and allergies to prevent allergic reactions and ensure resident satisfaction with their meals.
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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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Atrium Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| The Heights At Medical Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Remington Transitional Care Of San Antonio | 1 mi | ★★★★★ | 3 | 0 |
| Patriot Heights Health Care Center | 1 mi | ★★★★★ | 11 | 1 |
| Sorrento | 1 mi | ★★★★★ | 17 | 0 |
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