DEL RIO NURSING AND REHABILITATION CENTER
Government - Hospital district
60 Beds
TOUCHSTONE COMMUNITIES
Data: November 2025
Trust Grade
83/100
#43 of 1168 in TX
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Del Rio Nursing and Rehabilitation Center has a Trust Grade of B+, which means it is above average and recommended for families considering care options. It ranks #43 out of 1,168 facilities in Texas, placing it in the top half, and is the best option among the three facilities in Val Verde County. The facility is improving, having reduced its number of issues from 7 to 6 over the past year. Staffing is a concern, with a rating of 2 out of 5 stars, but the turnover rate is a low 15%, indicating that most staff remain for a good amount of time. While the center has received an average of $8,018 in fines and offers more RN coverage than 91% of Texas facilities, there are some notable incidents. One serious incident involved a resident who suffered a nasal fracture after being left unsupervised, indicating a lapse in care. Additionally, there were concerns about food safety, as the ice maker was found to have mold, which poses health risks. Lastly, two residents were improperly admitted under guard, raising issues about their rights. Overall, while there are strengths in RN coverage and a strong overall star rating, families should be aware of the facility's weaknesses in supervision and care practices.
- Trust Score
- B+
- In Texas
- #43/1168
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 15% annual turnover. Excellent stability, 33 points below Texas's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $8,018 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Texas. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
83/100
Top 3%
Needs review
7 → 6 violations
★★★★★
5.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 6 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (15%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (15%)
33 points below Texas average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
Federal Fines: $8,018
Below median ($33,413)
Minor penalties assessed
Chain: TOUCHSTONE COMMUNITIES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 18 deficiencies on record
1 actual harm
May 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, d...
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Based on interviews and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #37) reviewed for transmitted MDS data to the CMS System.
The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #37.
This failure could place residents at risk of not having their assessments transmitted timely which could cause a delay in treatment.
The findings included:
Record review of Resident #37's admission sheet documented an original admission date of 12/19/2024 with diagnoses which included type 2 diabetes mellitus, high blood pressure, and high cholesterol.
Record review of Resident #37's discharge summary documented a discharge date of 12/23/2024 to the resident's home.
Record review of Resident #37's admission MDS assessment, dated 12/23/2024, documented a BIMS score of 14 which indicated no cognitive impairment. Further review of Resident #37's medical record revealed no other MDS assessment and or transmittal to the CMS system with a status of Discharge - ARD: 12/23/2024 116 days overdue.
During an interview with the MDS Nurse on 5/02/25 at 1:23 PM, the MDS Nurse stated when a resident is discharged , they do a care plan meeting with the family to see what the plan is, and if the resident has the resources they need after discharge. The MDS Nurse stated when a resident is discharged , they must open a discharge MDS which is an assessment of the discharge they send to CMS with the discharge status of the resident. The MDS Nurse stated she must complete and submit the MDS discharge assessment. The MDS Nurse stated she signs each tab of the assessment, and then has the Regional Nurse Supervisor and the DON sign it. The MDS Nurse stated once all signatures are present, she sends the assessment to CMS. The MDS Nurse stated the discharge MDS assessment was probably not done because the resident left so soon; she missed it; and it was human error.
During an interview with the Administrator on 5/02/25 at 4:40 PM, the Administrator stated her expectation for MDS assessments was when a resident is discharged , the MDS Nurse should process the discharge assessment to CMS and double check herself. The Administrator stated the harm in not processing the discharge MDS assessment was that CMS would be unaware that the resident was no longer residing in the facility.
Record review of the facility policy titled Comprehensive Assessments, dated February 2017 and revised March 2023, noted assessments are conducted within fourteen days of the resident's admission to the community, when there has been a significant change in the resident's condition, quarterly, and annually (every twelve months).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #93) reviewed for pharmacy services.
The facility failed to ensure Resident #93's blood pressure results were documented in the electronic medical before administering a blood pressure medication per the physician's orders.
This failure could place residents at risk of not receiving the intended effect of their prescribed medications and a decreased quality of life.
The findings included:
Record review of Resident #93's admission sheet dated 5/2/2025, documented a [AGE] year old male with an admission date of 4/17/2025 with diagnoses which included cerebral infarction (when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts), seizure disorder, low blood pressure, depression, and anxiety.
Record review of Resident #93's annual MDS assessment, dated 4/26/2025, documented no BIMS score for the resident. Under section 0C100 Should Brief Interview for Mental Status (0C200-0C500) be Conducted?, no answer was recorded.
Record review of Resident #93's care plan with a creation date of 4/18/2025, documented the resident's refusal to follow care recommendations of the physician and clinical team with interventions including Provide education on options for care and reassure that choices will be respected. Provide education to me and or my family on the associated benefits of the recommended care and orders noted. Refer to Social Worker as indicated.
Record review of Resident #93's hospital Discharge summary, dated [DATE], documented the resident's active medication list including an order for Midodrine 10mg, give 1 tablet by mouth three times a day, hold if systolic blood pressure greater than 100.
Record review of Resident #93's MAR from April 2025 showed no documentation of Resident #93's blood pressure results before giving the resident's blood pressure medication.
During an observation and record review of medication administration with the facility CMA on 5/01/25 at 7:45 AM, the CMA collected the blood pressure cuff and medications for resident #93 including the resident's blood pressure medication and proceeded to the resident's room to measure the resident's blood pressure and administer the medications. Review of the directions for the blood pressure medication on the electronic medication administration record included parameters to hold the medication pending the result of the blood pressure. The resident refused to have his blood pressure measured and refused all medications. The CMA returned to the medication cart to dispose of the refused medications, document the refusal, and alert the nurse.
During an interview with the CMA on 5/01/25 at 4:10 PM, the CMA stated she takes Resident #93's blood pressure before dosing and is aware of the parameter but she does not document the measurement of the blood pressure on the resident's electronic medical record. The CMA stated she does not document the results of Resident #93's blood pressure because there is nowhere to record it. The CMA stated she had not told anyone there was nowhere to record the blood pressure results. When asked why she had not told anyone there was nowhere to document blood pressure results, the CMA stated, well, I don't, but I give it correctly.
During an interview with LVN A on 5/02/25 at 8:45 AM, LVN A stated if parameters are on the medication aide screen, results should be somewhere. LVN A stated she always takes the blood pressures of all residents with parameters, and we all write it in our brain, but that's not right.
During an interview with the Regional Administrator, the Administrator, and the DON on 5/02/2025 at 4:40 PM, the Administrator stated her expectation was for staff to follow physician orders and document a resident's blood pressure results in the notes section of the electronic medical record. The Administrator stated her expectation was for staff to communicate with her if they could not find an area in the medical record to document blood pressure results. The Administrator stated there was no harm to the resident, because the Medical Director discontinued the order with parameters the day before on 5/01/2025 and reordered the medication with no parameters.
Record review of the facility's policy titled Medication Administration, dated March 2019 and revised January 2024, documented if applicable and/or prescribed, take vital signs or tests prior to administration of the dose and administer medications as ordered by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to exercise their ri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States for 2 of 40 residents (Residents #93 and #94) reviewed for freedom of their rights.
1.
On 4/17/2025 Resident #93 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles.
2.
On 4/28/2025 Resident #94 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles.
These failures could place residents at risk for physical restraints not required to treat medical symptoms.
The findings included:
1.
A record review of Resident #93's administration record dated 5/2/2025 revealed Resident #93 was a [AGE] year-old male admitted on [DATE] with diagnoses which included cerebral infarction (stroke) and epilepsy (seizures).
A record review of Resident #93's care plan dated 4/18/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral (left and right) wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [SIC(ROOM)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition.
During an observation and interview on 4/29/25 at 3:44 PM revealed Resident #93 in his room lying in bed covered in blankets with 2 armed guards supervising him. Resident #93 pulled back his covers and demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #93 refused to comment on his wishes for restraints and or medical needs for restraints.
2.
A record review of Resident #94's administration record dated 5/2/2025 revealed Resident #94 was a [AGE] year-old male admitted on [DATE] with diagnoses which included chronic pulmonary disease and heart failure.
A record review of Resident #94's care plan dated 4/29/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral wrists, ankles, and abdominal back area, . other: US Marshall's supervisory needs in Rome [sic(room)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition.
During an observation and interview on 4/29/25 at 3:48 PM revealed Resident #94 in his room lying in bed with 2 armed guards supervising him. Resident #94 demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #94 refused to comment on his wishes for restraints and or medical needs for restraints.
During an interview on 4/29/25 at 3:50 PM LVN B stated she was the charge nurse for Residents #93 and #94. LVN B stated Residents #93 and #94 were prisoners under custody of the Marshals service and each one was guarded by 2 armed guards and each prisoner was restrained by hand cuffs, ankle cuffs and an abdominal chain. LVN B stated each one was admitted with the restraints and each one did not have any consents nor physician's orders for the restraints. LVN B believed the resident prisoners were restrained by the Marshals and not the facility. LVN B stated, [Resident #94] just arrived yesterday, and [Resident #93] has been here since 4/17/2025. LVN B stated she and other nurses checked on resident prisoners' skin under and around the restraints for skin integrity. LVN B stated, They never leave their rooms, except for showers which are provided late evenings when other residents are in their rooms.
During an interview on 4/29/25 at 4:50 PM the Health Services Administrator for the (Local) Detention Facility stated Resident # 94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Health Services Administrator stated the prisoners had medical needs for health care and security and the facility accepted the prisoners for care with the armed guards and the prisoners restrained. The Health Services Administrator stated per the Department of Justice the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms.
During an interview on 4/30/25 at 5:10 PM the Deputy U.S Marshal Detention Management Investigator stated Resident #94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Deputy Marshal stated the prisoners had medical needs for health care and security which the facility accepted the prisoners. The Deputy Marshal stated the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms.
During an observation and interview on 4/30/25 at 7:01 AM revealed Detention Guard C and Detention Guard D were in Resident #93's room guarding Resident #93. The detention guards stated Resident #93 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal.
During an observation and interview on 4/30/25 at 7:10 AM revealed Detention Guard E and Detention Guard F were in Resident #94's room guarding Resident #94. The detention guards stated Resident #94 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal.
During an interview on 5/2/2025 at 4:40 PM the Administrator and the DON stated Residents #93 and #94 were admitted for rehabilitation healthcare under the supervision of the U.S. Marshals Service and had the need to be restrained. The Administrator and the DON stated they believed the restraints were applied by the Marshals and not the facility. The Administrator and the DON stated the risks for residents was for residents to be restrained. The Administrator stated she would partner with the Marshal Service to safely discharge Residents #93 and #94.
A record review of the facility's Restraint Management policy dated January 2024, revealed, Compliance Guidelines:
The standard of practice at the community is to attain a home like environment; therefore, the community strives to be a restraint free environment. Physical or chemical restraints are not used for purpose of discipline or convenience, but only as required/ordered to treat the resident's medical symptoms.
Resident Rights - Each resident has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #24) reviewed for antipsychotic medication administration.
1.
Resident #24 was administered ziprasidone, an antipsychotic medication, in April 2025 without the resident's informed consent and understanding the medications potential side effects.
The deficient practices could place residents at risk for side effects for which they did not consent.
The findings included:
A record review of Resident #24's admission record dated 5/2/2025 revealed an admission date of 1/31/2025 with diagnoses which included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities which can interfere with activities of daily life) and anxiety.
A record review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 0 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with trouble sleeping and difficulty concentrating on tasks. Resident #24 needed total assistance with most ADL's and could use a wheelchair. Further review revealed Resident #24 was documented as receiving high-Risk Drugs. Resident #24 was documented as receiving antipsychotic medication.
A record review of Resident #24's care plan dated 2/1/2025 revealed, I have a self-care deficit - dementia . with psychotic disturbance . I use my wheelchair as a walker and refuse to use a regular walker, I ambulate without requesting assistance and refuse to be assisted by staff, I tend to refuse care at times such as brief changes, showers, and clothing changes from staff . I require psychotropic medications and I am at potential risk for side effects related to my medication regiment . my targeted behavior for the antipsychotic is: aggressive [sic(aggression)] towards others . monitor, document, report, to medical doctor as needed signs and symptoms of psychotropic drug complications; altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation,
A record review of Resident #24's physician's orders dated 4/29/2025 revealed the physician prescribed for Resident #24 to receive ziprasidone (an antipsychotic medication) 10 mg injections as needed every 8 hours .
A record review of Resident #24's Consent for Antipsychotic or Neuroleptic Medication Treatment form dated 4/18/2025, revealed the form was signed by Resident #24's representative however the form lacked any information for risks and benefits. The form instructed, you may attach prepared documents that state the risks and benefits of the proposed major medical treatment, procedure, specified. however, all questions must be addressed on this forum. the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: . the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications is indicated:
During an interview on 4/30/2025 at 1:19 PM Resident #24's representative stated she recalled receiving reports shortly after Resident #24's admission concerning Resident #24's aggressive behaviors towards peer residents and staff along with Resident #24's confused anxiety and refusals for medication and hygiene care which led to the physician's recommendation for a drug that could calm Resident #24. Resident #24's representative stated she signed a permission slip for Resident #24 to receive the drug but was unaware of any risks for side effects and believed the drug would be a pill and not an injection. Resident #24's representative stated she learned Resident #24 had received the drug multiple times since the end of April 2025 and believed the drug had helped Resident #24 but she now had concerns about the injection and the potential risks for side effects.
During an interview on 5/1/2025 at 1:40 PM the ADON stated Resident #24 had a history of aggression towards peers and staff and had been prescribed ziprasidone on 4/29/2025 and had been administered the medication via an injection several times in April 2025. The ADON stated Resident #24's representative had consented for the medication administration and was documented on the Consent for Antipsychotic or Neuroleptic Medication Treatment form dated 4/18/2025. The ADON stated upon inspection of the document the form lacked any information for risks and benefits. The ADON stated the resident should be informed of the proposed medication's potential risks versus the intended benefits prior to the administration. The ADON stated she was unaware of how the information was not documented.
During an interview on 5/2/2025 at 5:02 PM the Administrator and the DON stated the expectation for anti-psychotic medication administration was for the resident and or the resident's representative to receive informed consent prior to the drugs administration. The DON stated the risk to residents who did not receive informed consent could be receiving the medications without understanding the potential benefits versus the potential risks of the medications administered. The DON stated the system in place to ensure informed consents prior to medication administration was for the IDT to meet daily and review the medication orders and follow up with consents.
A record review of the facility's Psychotropic Medications & Gradual Dose Reduction policy dated January 2023 revealed, The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits of therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each resident was free from physical or ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms, for 2 0f 40 residents (Residents #93 and #94) reviewed for physical restraints.
1.
On 4/17/2025 Resident #93 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles.
2.
On 4/28/2025 Resident #94 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles.
These failures could place residents at risk for physical restraints not required to treat medical symptoms.
The findings included:
1.
A record review of Resident #93's administration record dated 5/2/2025 revealed Resident #93 was a [AGE] year-old male admitted on [DATE] with diagnoses which included cerebral infarction (stroke) and epilepsy (seizures).
A record review of Resident #93's care plan dated 4/18/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral (left and right) wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [SIC(ROOM)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition.
During an observation and interview on 4/29/25 at 3:44 PM revealed Resident #93 in his room lying in bed covered in blankets with 2 armed guards supervising him. Resident #93 pulled back his covers and demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #93 refused to comment on his wishes for restraints and or medical needs for restraints.
2.
A record review of Resident #94's administration record dated 5/2/2025 revealed Resident #94 was a [AGE] year-old male admitted on [DATE] with diagnoses which included chronic pulmonary disease and heart failure.
A record review of Resident #94's care plan dated 4/29/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [sic(room)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition.
During an observation and interview on 4/29/25 at 3:48 PM revealed Resident #94 in his room lying in bed with 2 armed guards supervising him. Resident #94 demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #94 refused to comment on his wishes for restraints and or medical needs for restraints.
During an interview on 4/29/25 at 3:50 PM LVN B stated she was the charge nurse for Residents #93 and #94. LVN B stated Residents #93 and #94 were prisoners under custody of the Marshals service and each one was guarded by 2 armed guards and each prisoner was restrained by hand cuffs, ankle cuffs and an abdominal chain. LVN B stated each one was admitted with the restraints and each one did not have any consents nor physician's orders for the restraints. LVN B believed the resident prisoners were restrained by the Marshals and not the facility. LVN B stated, [Resident #94] just arrived yesterday, and [Resident #93] has been here since 4/17/2025. LVN B stated she and other nurses checked on resident prisoners' skin under and around the restraints for skin integrity. LVN B stated, They never leave their rooms, except for showers which are provided late evenings when other residents are in their rooms.
During an interview on 4/29/25 at 4:50 PM the Health Services Administrator for the (Local) Detention Facility stated Resident # 94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Health Services Administrator stated the prisoners had medical needs for health care and security and the facility accepted the prisoners for care with the armed guards and the prisoners restrained. The Health Services Administrator stated per the Department of Justice the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms.
During an interview on 4/30/25 at 5:10 PM the Deputy U.S Marshal Detention Management Investigator stated Resident #94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Deputy Marshal stated the prisoners had medical needs for health care and security which the facility accepted the prisoners. The Deputy Marshal stated the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms.
During an observation and interview on 4/30/25 at 7:01 AM revealed Detention Guard C and Detention Guard D were in Resident #93's room guarding Resident #93. The detention guards stated Resident #93 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal.
During an observation and interview on 4/30/25 at 7:10 AM revealed Detention Guard E and Detention Guard F were in Resident #94's room guarding Resident #94. The detention guards stated Resident #94 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal.
During an interview on 5/2/2025 at 4:40 PM the Administrator and the DON stated Residents #93 and #94 were admitted for rehabilitation healthcare under the supervision of the U.S. Marshals Service and had the need to be restrained. The Administrator and the DON stated they believed the restraints were applied by the Marshals and not the facility. The Administrator and the DON stated the risks for residents was for residents to be restrained. The Administrator stated she would partner with the Marshal Service to safely discharge Residents #93 and #94.
A record review of the facility's Restraint Management policy dated January 2024, revealed, Compliance Guidelines:
The standard of practice at the community is to attain a home like environment; therefore, the community strives to be a restraint free environment. Physical or chemical restraints are not used for purpose of discipline or convenience, but only as required/ordered to treat the resident's medical symptoms.
Resident Rights - Each resident has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents did not receive antipsychotic medications ordered...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents did not receive antipsychotic medications ordered as needed for longer than 14 days for 1 of 8 residents (Resident #24) reviewed for antipsychotic medication administration.
1.
Resident #24 was prescribed ziprasidone, an antipsychotic medication, as needed without an end date.
The deficient practices could place residents at risk for indefinitely receiving an antipsychotic medication.
The findings included:
A record review of Resident #24's admission record dated 5/2/2025 revealed an admission date of 1/31/2025 with diagnoses which included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities which can interfere with activities of daily life) and anxiety.
A record review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 0 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with trouble sleeping and difficulty concentrating on tasks. Resident #24 needed total assistance with most ADL's and could use a wheelchair. Further review revealed Resident #24 was documented as receiving high-Risk Drugs. Resident #24 was documented as receiving antipsychotic medication.
A record review of Resident #24's care plan dated 2/1/2025 revealed, I have a self-care deficit - dementia . with psychotic disturbance . I use my wheelchair as a walker and refuse to use a regular walker, I ambulate without requesting assistance and refuse to be assisted by staff, I tend to refuse care at times such as brief changes, showers, and clothing changes from staff . I require psychotropic medications and I am at potential risk for side effects related to my medication regiment . my targeted behavior for the antipsychotic is: aggressive [sic(aggression)] towards others . monitor, document, report, to medical doctor as needed signs and symptoms of psychotropic drug complications; altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation,
A record review of Resident #24's physician's orders dated 4/29/2025 revealed the physician prescribed for Resident #24 to receive ziprasidone (an antipsychotic medication) 10 mg injections as needed every 8 hours. Further review revealed no end date for the medication.
During an interview on 4/30/2025 at 1:19 PM Resident #24's representative stated she recalled receiving reports shortly after Resident #24's admission concerning Resident #24's aggressive behaviors towards peer residents and staff along with Resident #24's confused anxiety and refusals for medication and hygiene care which led to the physician's recommendation for a drug that could calm Resident #24. Resident #24's representative stated she signed a permission slip for Resident #24 to receive the drug but was unaware of any risks for side effects and believed the drug would be a pill and not an injection. Resident #24's representative stated she learned Resident #24 had received the drug multiple times since the end of April 2025 and believed the drug was prescribed indefinitely.
During an interview on 5/1/2025 at 1:40 PM the ADON stated Resident #24 had a history of aggression towards peers and staff and had been prescribed ziprasidone on 4/29/2025 and had been administered the medication via an injection several times in April 2025. The ADON stated Resident #24's medication order for ziprasidone had no end date. The ADON stated she could not opine on whether the order needed an end date and would review the order with the DON.
During an interview on 5/2/2025 at 5:02 PM the Administrator and the DON stated the expectation for anti-psychotic medication administration was for the order not to exceed 14 days at which time the order would be reviewed with the physician. The DON stated the risk to residents would be potentially receiving the medication longer than 14 days. The DON stated the system in place to ensure antipsychotic medications were not prescribed longer than 14 days was for the IDT to meet daily and review the medication orders for end dates and follow up with the prescriber for order clarifications.
A record review of the facility's Psychotropic Medications & Gradual Dose Reduction policy dated January 2023 revealed, The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits
Apr 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to voice grievances to the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances to include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay for 1 of 8 residents (Resident #17) reviewed for grievances.
RN E received a grievance from Resident #17's representative and did not initiate a grievance report.
This failure could place residents at risk for not having grievances heard, addressed, and resolved.
The findings included:
A record review of Resident #17's admission record dated 04/10/2024, revealed an admission date of 03/01/2024 with diagnoses which included a pressure ulcer of the sacral region (a wound to her buttocks), depression and anxiety disorder.
A record review of Resident #17's admission MDS assessment dated [DATE] revealed Resident #17 was a [AGE] year-old female admitted for long term care with wounds to her buttocks and assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment.
A record review of Resident #17's care plan dated 04/10/2024 revealed, .I have incontinence .Incontinent Care assistance every shift and as needed.
A record review of Resident #17's nurse's notes revealed RN E documented on 03/27/2024 at 06:18 AM, Residents (Representative) came in at 2320 (11:20 PM 03/26/2024) to check on Resident. (Representative) approached nurses' station and stated that Resident had called her and her (Family Member) around 1830 (06:30 PM) to inform them that Resident had been on call light for a while wanting to be changed but no one had gone into change her. (Representative) stated she called facility around 1850 (06:50 PM) but no answer. This nurse informed [family member] that she will be monitor closely and changed.
During an interview on 04/10/2024 at 7:29 PM RN E stated she worked the 10:00 PM 03/26/2024 to 06:00 AM 03/27/2024 shift and cared for Resident #17. RN E recalled an event where Resident #17's family member presented at the facility's front door ringing the doorbell around midnight. RN E stated Resident #17's representative entered the facility and went to see Resident #17 and then returned to the nurse's station to inquire about Resident #17's evening. RN E stated she gave Resident #17's representative a report that she and her CNAs had been caring for Resident #17 to include rounding on the resident every 2 hours at a minimum and had provided incontinent care. RN E stated she then received a report from Resident #17's representative which included her complaint that Resident #17 called her (Resident #17's representative) and her family member to complain she needed incontinent care, used her call light, and no one would respond. RN E stated Resident #17's representative claimed she had attempted to call the facility without success and then decided to visit the facility and Resident #17. RN E stated she reassured Resident #17's representative and would continue to answer call lights, round on the resident every 2 hours or more often and provide incontinent care. RN E stated she documented the event in Resident #17 nurses notes but had not initiated a grievance report. RN E stated she had not considered initiating a grievance report but with a review of the event RN E stated she could have generated a grievance report so that the Administrator could review the grievance and address Resident #17's complaint. RN E stated Resident #17 had received the care, but her grievance was not documented, and the Administrator was not provided the opportunity to recognize Resident #17's complaint.
During an interview on 04/11/2024 at 10:20 AM Resident #17 stated when she was at her home her health had declined to the point where she was bed bound, incontinent, developed a bed sore on her backside, and was hospitalized . Resident #17 stated after her hospitalization she was admitted into the facility, and she had anxiety regarding her fear of neglect for care with her incontinence and her bed sore, and potential for injury due to a fall. Resident #17 stated she did recall an event when she did receive incontinent care and afterwards felt another incontinent episode and used her call light for assistance and stated, it was after dinner around bedtime. I was in bed. Resident #17 stated she called her Representative and (family member) to report the lack of someone answering the call light. Resident #17 stated eventually staff did answer her light and was now happy with the care she received at the facility and wished for the staff to not get into trouble, and further stated, I told (Resident #17's representative) not to make trouble. They (staff) take care of me.
During an interview on 04/11/2024 at 01:20 PM the Administrator stated she had not received a grievance report on behalf of Resident #17's complaint on 03/27/2024. The Administrator stated she had reviewed RN E's documentation for the evening of 03/26/2024 to 03/27/2024, interviewed the staff and the resident for the event, and had concluded Resident #17 had received the care needed but none the less the grievance could have been documented for her review and possible interventions. The Administrator stated the potential risk for not generating a grievance report was that residents may not have their grievances heard, investigated, and documented. The Administrator stated the grievance reports were reviewed daily by the leadership team and if areas of improvement were identified the grievances would be reviewed during the Quality Assurance and Performance Improvement meetings.
A record review of the facility's Grievances policy dated December 2023, revealed, The investigation of complaints and grievances is a vital function to protect the health, safety, and welfare of residents. The Administrator is designated as the Grievance Official and is responsible for ensuring that all complaints and grievances are investigated and resolved in a timely and appropriate manner. This responsibility includes: overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the community; and maintaining the confidentiality of all information associated with grievances . each resident has the right to receive prompt resolution of grievances, including those regarding the behavior of other residents .filing grievances is not limited to a formal, written grievance process but may include a residence verbalized or written complaint to any community team member or a grievance made anonymously
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 8 residents (Resident #17) reviewed for reporting allegations of neglect.
RN E received an allegation of neglect from Resident #17's representative and did not report the allegation to the abuse, neglect, and exploitation prevention coordinator, the Administrator.
This failure could place residents at risk for not having allegations reported.
The findings included:
A record review of r esident #17's admission record dated 04/10/2024, revealed an admission date of 03/01/2024 with diagnoses which included a pressure ulcer of the sacral region (a wound to her buttocks), depression and anxiety disorder.
A record review of Resident #17's admission MDS assessment dated [DATE] revealed Resident #17 was a [AGE] year-old female admitted for long term care with wounds to her buttocks and assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment.
A record review of Resident #17's care plan dated 04/10/2024 revealed, .I have incontinence .Incontinent Care assistance every shift and as needed.
A record review of resident #17's nurse's notes revealed RN E documented on 03/27/2024 at 06:18 AM, Residents (Representative) came in at 2320 (11:20 PM 03/26/2024) to check on Resident. (Representative) approached nurses' station and stated that Resident had called her and her (Family Member) around 1830 (06:30 PM) to inform them that Resident had been on call light for a while wanting to be changed but no one had gone into change her. (Representative) stated she called facility around 1850 (06:50 PM) but no answer. This nurse informed daughter that she will be monitor closely and changed.
During an interview on 04/10/2024 at 7:29 PM RN E stated she worked the 10:00 PM 03/26/2024 to 06:00 AM 03/27/2024 shift and cared for Resident #17. RN E recalled an event where Resident #17's family member presented at the facility's front door ring the doorbell around midnight. RN E stated Resident #17's representative entered the facility and went to see Resident #17 and then returned to the nurse's station to inquire about Resident #17's evening. RN E stated she gave Resident #17's representative a report that she and her CNA's had been caring for Resident #17 to include rounding on the resident every 2 hours at a minimum and had provided incontinent care. RN E stated she then received a report from Resident #17's representative which included her complaint Resident #17 called her (Resident #17's representative) and her family member to complain she needed incontinent care, used her call light, and no one would respond. RN E stated Resident #17's representative claimed she had attempted to call the facility without success and then decided to visit the facility and Resident #17. RN E stated she reassured Resident #17's representative and would continue to answer call lights, round on the resident every 2 hours or more often and provide incontinent care. RN E stated she documented the event in resident #17 nurses notes but had not initiated a grievance report nor reported the allegation of neglect to the Administrator. RN E stated she had not considered the complaint as an allegation of but with a review of the event RN E stated she could have generated a grievance report so that the Administrator could review the grievance and address Resident #17's complaint. RN E stated Resident #17 had received the care, but her grievance was not documented, and the a dministrator was not provided the opportunity to recognize Resident #17's allegation of neglect.
During an interview on 04/11/2024 at 10:20 AM Resident #17 stated she was at her home her health had declined to the point where she was bed bound, incontinent, developed a bed sore on her backside, and was hospitalized . Resident #17 stated after her hospitalization she was admitted into the facility, and she had anxiety for her fear of neglect for care with her incontinence and her bed sore, and potential for injury due to a fall. Resident #17 stated she did recall an event when she did receive incontinent care and afterwards felt another incontinent episode and used her call light for assistance, it was after dinner around bedtime, I was in bed. Resident #17 stated she called her Representative and (Family member) to report the lack of someone answering the call light. Resident #17 stated eventually staff did answer her light and was now happy with the care she received at the facility and wished for the staff to not get into trouble, I told (Resident #17's representative) not to make trouble, they (staff) take care of me.
During an interview on 04/11/2024 at 01:20 PM the Administrator stated she had not received a grievance report or allegation of neglect on behalf of Resident #17's complaint on 03/27/2024. The Administrator stated she had reviewed RN E's documentation for the evening of 03/26/2024 to 03/27/2024, interviewed the staff and the resident for the event, and had concluded resident #17 had received the care needed but none the less the grievance could have been documented for her review and possible interventions. The Administrator stated the potential risk for not generating a grievance report was that residents may not have their grievances heard, investigated, and documented. The Administrator stated the grievance reports are reviewed daily by the leadership team and if areas of improvement are identified the grievances would be reviewed during the Quality Assurance and Performance Improvement meetings .
A record review of the facility's Abuse Guidance: Preventing, Identifying and Reporting policy dated October 2022, revealed, .Reporting Allegations or suspicions of Abuse . a community owner, operator or team member who has knowledge of an allegation of, or cause to believe that, abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for 1 of 8 residents (Resident #10) reviewed for drug labeling.
The facility failed to remove Resident #10's expired insulin lispro injection pen from the medication cart.
This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.
The findings included:
A record review of r esident #10's admission record, dated 04/11/2024, revealed an admission date of 01/05/2024 with diagnoses which included type 2 diabetes (the body either doesn't produce enough insulin, a hormone that regulates blood sugar, or doesn't use it effectively. This leads to elevated blood sugar levels.)
A record review of resident #10's annual MDS assessment, dated 02/07/2024, revealed resident #10 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment.
A record review of resident #10's Care Plan dated 04/11/2024, revealed, I have diabetes and take insulin .I will not experience complications associated with my diabetes through the next review date .Administer my medications as recommended by my doctor, monitor labs as indicated
A record review of Resident #10's Physician's orders dated 04/11/2024 revealed resident #10 was prescribed insulin lispro twice a day, at 07:30 AM and at 05:00 PM, per a sliding scale according to Resident #10s blood sugar measurements prior to administration of the insulin.
A record review of the insulin lispro injection pen manufacturers website, https://uspl.lilly.com/humalog/humalog.html#ug1, accessed 04/11/2024, revealed, .Preparing your Pen; Wash your hands with soap and water .Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen.
An observation on 04/10/2024 at 03:54 PM of the facility's B-Hall nurses medication cart revealed an insulin lispro injection pen for Resident #10. The injection pen had a handwritten label date opened: 3-5-24 (LVN A initials).
During an interview on 04/10/2024 at 03:56 PM LVN A stated the insulin lispro injection pen belonged to Resident #10. LVN A stated the insulin pen was labeled with the date the pen was removed from refrigeration and placed into service, 03/05/2024. LVN A stated the insulin injection pen had a shelf life of 28 days outside of refrigeration and after 28 days the pen should be discarded. LVN A stated reviewed a calendar and assessed the insulin pen as being 36 days out of refrigeration and 8 days past the expiration date. LVN A stated she would remove the insulin pen from the medication cart and discard the insulin pen. LVN A stated when the pen was in the medication cart it was available for administration and should have been discarded 28 days after being removed from refrigeration. LVN A stated the potential risk for resident #10 receiving expired insulin was high blood sugar .
During an interview on 04/12/2024 at 1:00 PM the DON stated the expectation for nurses removing insulin pens from refrigeration was to label the injection pen with the date when the pen was removed from refrigeration and the date for when the insulin injection pen would expire and discarded. The DON stated for insulin lispro the manufacturer recommended the insulin pen should be discarded after 28 days without refrigeration. The DON stated the insulin pen should have been discarded after 28 days. The DON stated the risk for residents receiving expired insulin was residents may not receive the intended therapeutic effects of their prescribed medications .
During an interview on 04/11/2024 at 01:20 PM the Administrator stated she was not a clinician and referred to the DON's supervision and agreed with the DON residents should not receive expired medications and could be at risk for potentially receiving expired medications.
A record review of the facility's Pharmacy Services: Provision of Medications and Biologicals policy, dated November 2023, revealed, .Labeling of medications and biologicals. Medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug labeling regulations. Even though the pharmacy is responsible for labeling medications and biologicals, the community is responsible for ensuring that labeling requirements are being met. The critical elements of the drug label include: .expiration dates
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents were free of any significant medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #10) reviewed for drug labeling.
LVN A, LVN B, LVN C, and LVN D administered Resident #10 expired insulin lispro 11 times out of a potential 17 times from 04/03/2024 to 04/11/2024.
This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.
The findings included:
A record review of r esident #10's admission record, dated 04/11/2024, revealed an admission date of 01/05/2024 with diagnoses which included type 2 diabetes (the body either doesn't produce enough insulin, a hormone that regulates blood sugar, or doesn't use it effectively. This leads to elevated blood sugar levels.).
A record review of resident #10's annual MDS assessment, dated 02/07/2024, revealed resident #10 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment.
A record review of resident #10's Care Plan dated 04/11/2024, revealed, I have diabetes and take insulin .I will not experience complications associated with my diabetes through the next review date .Administer my medications as recommended by my doctor, monitor labs as indicated
A record review of Resident #10's Physician's orders dated 04/11/2024 revealed resident #10 was prescribed insulin lispro twice a day, at 07:30 AM and at 05:00 PM, per a sliding scale according to Resident #10s blood sugar measurements prior to administration of the insulin. The sliding scale was prescribed as: if the blood sugar measurement is 0 - 179 then give 0 units; 180 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 999 = 10 units.
A record review of the insulin lispro injection pen manufacturers website , https://uspl.lilly.com/humalog/humalog.html#ug1, accessed 04/11/2024, revealed, .Preparing your Pen; Wash your hands with soap and water .Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen.
An observation on 04/10/2024 at 03:54 PM of the facility's B-Hall nurses medication cart revealed an insulin lispro injection pen for Resident #10. The injection pen had a handwritten label date opened: 3-5-24 (LVN A initials).
A record review of the calendar revealed the insulin injection pen would have become expired on the 28th day from 03/05/2024 on 04/03/2024.
A record review of Resident #10's April 2024 medication administration record dated 04/11/2024 revealed resident #10 could have been administered insulin lispro 17 times from 04/03/2024 to 04/11/2024 and was administered expired insulin lispro 11 times as follows :
1.
On 03/03/2024 LVN A administered 6 units of expired insulin lispro to Resident #10 at 05:00 PM.
2.
On 03/04/2024 LVN B administered 2 units of expired insulin lispro to Resident #10 at 07:30 AM.
3.
On 03/04/2024 LVN A administered 6 units of expired insulin lispro to Resident #10 at 05:00 PM.
4.
On 03/05/2024 LVN B administered 2 units of expired insulin lispro to Resident #10 at 07:30 AM.
5.
On 03/05/2024 LVN C administered 6 units of expired insulin lispro to Resident #10 at 05:00 PM.
6.
On 03/06/2024 LVN A administered 4 units of expired insulin lispro to Resident #10 at 05:00 PM.
7.
On 03/07/2024 LVN D administered 4 units of expired insulin lispro to Resident #10 at 07:30 AM.
8.
On 03/07/2024 LVN DB1 Administered 4 units of expired insulin lispro to Resident #10 at 05:00 PM
9.
On 03/08/2024 LVN C administered 8 units of expired insulin lispro to Resident #10 at 05:00 PM.
10.
On 03/09/2024 LVN A administered 8 units of expired insulin lispro to Resident #10 at 05:00 PM.
11.
On 03/10/2024 LVN A Administered 6 units of expired insulin lispro to Resident #10 at 05:00 PM.
During an interview on 04/10/2024 at 03:56 PM LVN A stated the insulin lispro injection pen belonged to Resident #10. LVN A stated the insulin pen was labeled with the date the pen was removed from refrigeration and placed into service, 03/05/2024. LVN A stated the insulin injection pen had a shelf life of 28 days outside of refrigeration and after 28 days the pen should be discarded. LVN A stated she reviewed a calendar and assessed the insulin pen as 9 days past the expiration date. LVN A stated she would removed the insulin pen from the medication cart and discard the insulin pen. LVN A stated when the pen was in the medication cart it was available for administration and should have been discarded 28 days after being removed from refrigeration. LVN A stated she may have administered the expired insulin to Resident #10 and the potential risk for resident #10 receiving expired insulin was high blood sugar.
During an interview on 04/12/2024 at 1:00 PM the DON stated the expectation for nurses removing insulin pens from refrigeration was to label the injection pen with the date when the pen was removed from refrigeration and the date for when the insulin injection pen would expire and discarded. The DON stated for insulin lispro the manufacturer recommended the insulin pen be discarded after 28 days without refrigeration. The DON stated the insulin pen should have been discarded after 28 days. The DON stated a record review of Resident #10's April 2024 medication administration record revealed LVN A, LVN B, LVN C, and LVN D had documented they administered the insulin injection for resident #10 while there being only 1 injection pen, and expired injection pen for Resident #10, available on the cart. The DON stated the risk for residents receiving expired insulin was residents may not receive the intended therapeutic effects of their prescribed medications.
During an interview on 04/11/2024 at 01:20 PM the Administrator stated she was not a clinician and referred to the DON's supervision and agreed with the DON residents should not receive expired medications and could be at risk for potentially receiving expired medications.
A record review of the facility's Pharmacy Services: Provision of Medications and Biologicals policy, dated November 2023, revealed, .Labeling of medications and biologicals. Medications and biologicals are labeled in accordance with currently accepted professional standards and with local and state drug labeling regulations. Even though the pharmacy is responsible for labeling medications and biologicals, the community is responsible for ensuring that labeling requirements are being met. The critical elements of the drug label include: .expiration dates
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitch...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that:
The facility failed to maintain the cleanliness of the facility ice maker.
The failure could place residents at risk for cross-contamination and foodborne illnesses.
The findings included:
Observation on 04/10/2024 at 5:06 PM revealed a black substance build-up within the walls of the ice maker in the kitchen storage room.
Interview on 04/10/2024 at 5:06 PM, the DM stated the kitchen and maintenance staff were both responsible for cleaning the ice maker monthly . The DM stated that the substance in the ice machine appeared to be mold and could be dangerous to residents as it could make them sick.
Interview on 04/12/2024 at 11:55 AM, the Administrator stated her expectation was for the ice maker to be cleaned weekly and emptied out and cleaned thoroughly monthly. The Administrator stated that the ice machine appeared dirty. The Administrator further stated that no residents had had any GI issues.
Interview on 04/12/2024 at 11:57 AM, the DON stated that her expectation was for the ice machine to be clean. The DON also stated that the ice machine appeared dirty and could potentially affect residents' GI systems but that no residents had had GI issues.
Record review of facility policy titled, Ice Machines, undated, revealed, The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day.
Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident in 2 of 28 multipl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a minimum of 80 square feet per resident in 2 of 28 multiple resident rooms as required for (Rooms #14, #21) reviewed for the 80 square feet per Resident requirement .
The facility failed to ensure all resident rooms met the minimum size requirements.
This deficient practice could affect residents who may reside in these rooms and not allow sufficient room to carry out activities of daily living care, or have the room furnished as they would like and place them at risk for decreased quality of life.
The findings included:
Record review of HHSC Form-3740, dated 4/9/2024, reflected rooms #14 and #21 were indicated as Title 18/19 beds with a total facility occupancy of 60 beds.
Interview on 04/12/2024 at 11:00 AM with the Administrator revealed 2 resident Rooms (#14, #21) required a room waiver and she wanted to continue the room waiver as the size of the rooms had not changed.
Review of the facility daily census dated 04/09/2024 revealed resident room [ROOM NUMBER] had no occupants, and #21 had 1 occupant.
Mar 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision.
On 01/30/24, Resident #1 was left unsupervised and suffered an injury, bilateral nasal bone fracture and ten sutures to the forehead, from an unwitnessed fall from a wheelchair to the floor. The facility did not provide adequate supervision.
The noncompliance was identified as PNC. The noncompliance began on 01/30/24 and ended on 02/06/24. The facility had corrected the noncompliance before the survey began.
This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life.
The findings were:
Record review of Resident#1's face sheet, dated 3/26/24, revealed the resident was admitted on [DATE] and re-admitted [DATE] and 5/27/22 with diagnoses that included: Parkinson's disease (neurological disease), dementia, anticoagulants (blood thinners) , UTI (urinary tract infection), and lack of coordination. Resident was a female age [AGE]. The RP was listed as: a family member.
Record review of Resident#1's quarterly MDS assessment, dated 2/11/24 revealed:
o
BIMS Score was Zero (severe impairment )
o
ADLs were: bowel and bladder: incontinent of both. Transfer was listed as resident being dependent and mechanical lift. Bed mobility was dependent. ROM was listed as impairment to lower extremity. Assistive devises included a customized innovative W/C.
Record review of Resident #1's CP reflected: the resident's assistive devise was a wheelchair, and the goal was Resident will experience safe transfers . through use of mechanical lift. The transfer required Total Lift X 2 Team Members. The CP also reflected that the resident was at risk for falls due to the diagnosis of Parkinson's and interventions included: avoid leaving resident unattended for excessive periods. Likewise, staff was to observe to ensure appropriate use of safety/assistive devices. Preventive fall measures included: low bed, call light, beside mat, room next to nurse station, routine rounds, scoop mattress, and a customized innovative wheelchair.
Record review of resident #1's physician's orders dated February 2024 revealed order for a UTI: order was as follows [initiated 2/1/24 and completed 2/6/24] Ceftriaxone( Sodium) Solution Reconstituted 1 GM . Use 1 gram intravenously every 24 hours for Empiric Treatment for 5 Days.
Record review of Resident#1's Physician' Orders, dated March 2024, reflected: monitor the resident's forehead every shift. Monitoring also included monitoring for Anxious/Restless/Panic. The Physician's order included resident prescribed an Anti-coagulant (Xarelto 20 mgs once per day).
Record review of Resident#1's MAR dated January 2024 reflected the following anticoagulant: Xarelto 20 mgs once per day.
Record review of Resident#1's Skin Assessments reflected : (dated 1/31/24 ) laceration to forehead: 2.9 cm X 0.9 cm (10 sutures) and 3 bruises to face and left finger . Current skin assessment (dated 3/20/24) reflected skin intact with a bruise to the forehead.
Record review of Resident #1's SBAR dated 1/30/24 revealed: Laceration to the forehead; sent to ER.
Record review of Resident #1's fall risk assessment dated [DATE] revealed a description of High risk.
Record review of Resident#1's TAR (dated February 2024) revealed, the resident received treatment for laceration to forehead. Treatment was to cleanse with normal salient, pad dry, leave open to air twice per day. Also, monitor the sutures to facial area, and discoloration every shift.
Record review of Resident#1's hospital record, dated 1/30/24, reflected: unwitnessed fall with possible nose fracture on blood thinners. CT dated 1/31/24 revealed: bilateral nasal bone fracture. Ten sutures to the forehead.
Record review of Resident #1's hospital labs dated 1/30/24 revealed the resident had a UTI at the time of fall.
Record review of Resident #1's rehab assessment dated [DATE] revealed: resident was an 80- year- old female patient who was referred for skilled PT Evaluation and Treatment for range of motion, mobility, to enhance balance, and coordination. Resident #1's assessment reflected she had limitations in bed mobility, balance, and positioning.
Record review of Resident #1's Rehab note at discharge, dated 1/14/23 authored by PT C reflected: improved to partial and minimal assistance with rolling. But the resident required maximum assistance with transfer from W/C to bed.
Record review of Resident #1's assessment on 2/6/24 and nurse note on 2/6/24 revealed: RP refused rehab services. RP wanted to wait until resident was better from fall on 01/30/24.
Record review of Resident #1's rehab note dated 01/30/24 by Rehab Director reflected: RP was called but refused referral for skilled therapy services and W/C management.
Record review of Resident #1' Nurse note dated 01/31/23 at 3:18 PM by the DON reflected: resident returned from hospital (one day stay) with nasal fracture and laceration to center of forehead with sutures. CT scan was negative. MD notified and Eliquis (anticoagulant medication) was withheld for 7 days.
Record review of Resident#1's Nurse Note, dated 01/30/24 at 6:50 PM authored by LVN B reflected: CNA A came running out of Resident #1's room telling LVN B that the resident had fallen out of the W/C. LVN B found Resident #1 faced down with blood on the floor. First aid was administered and another nurse arrived to assist. MD was notified and the resident was sent to the ER. The DON and RP were also notified.
During an observation and interview on 3/26/24 at 11:31 AM, Resident #1 was in an innovative customized W/C [ chair made to fit a resident for posture and comfort; not a restraint] and was alert and not oriented. Resident's room had a pressure release mattress, call light was present, scoop mattress, clutter free room, and bed was at lowest position. Resident had impairment to lower limbs. The resident's specialized W/C had working breaks and was tilted at a 20-degree angle. Resident #1's Hoyer sling was on the chair and the resident wore skid proof soaks. The resident had a bruise to the right of the forehead. The bruise color was yellow and blue. There was no fracture to the nose and sutures were not present to the forehead. The resident could not answer any direct questions. The resident was unable to lift herself out of the specialized wheelchair.
During an interview on 3/16/24 at 11:35 AM, the DON stated: CNA A informed her that resident was taken to her room on 01/30/24 for a mechanical transfer from wheelchair to bed. The DON stated CNA A responded to a call light and left the resident unsupervised for about 5 minutes. The DON stated that when CNA A returned to the resident's room she found her on the floor. The specialized wheel chair had not fallen with the resident. The DON stated: Resident #1 used her upper strength to pull out of the wheelchair and suffered a fall with an injury. The hospital x-ray revealed a fracture to the nose and an injury to the head requiring sutures. We conducted training on fall prevention for the nursing staff. The DON stated that 100% of nursing staff was in-serviced on date range of 1/31/24 (nursing staff on 1/31/24 equaled thirty paid staff). The DON stated the in-service was on fall prevention, monitoring, and abuse and neglect. The DON stated the resident likely pulled her weight forward and fell to the floor. The DON stated the roommate did not witness the fall. Instead, the roommate entered the room after CNA A left and found Resident #1 on the floor and triggered the call light. The DON's expectation was that the CAN sought assistance from another nurse aide for the answering of the call light and not leave a resident unsupervised that was pending a mechanical lift; and could pull herself forward on a specialized wheelchair.
During an interview on 3/26/24 at 11:44 AM, CNA A stated: she had provided ADL assistance to Resident #1 for about six months which included transfer with the use of a mechanical lift. CNA A stated that after dinner on 01/30/24, she took the resident to her room, put on the breaks to the special W/C and responded to a call light. The CNA A stated the resident was in a reclined position, she was calm, and not agitated in the W/C when taken to the room. The CNA A stated, I left the resident unsupervised for about five minutes. The roommate [Resident #2] triggered the call light. I found the resident on the floor with blood on the floor. I went to get help from the charge nurse [LVN B]. The resident was unable to explain the fall. The special w/c was stationary with the breaks on. CNA A stated that two staff were needed for a Hoyer lift and she did not bring the Hoyer lift with her. CNA A stated she did not take another staff with her in anticipation to transfer her from bed to W/C. CNA A stated her plan was to get the Hoyer lift and another staff member when she was ready to do the mechanical lift. CNA A stated that she was trained that a mechanical lift required two staff members and a resident had to be monitored during the performance of a mechanical lift. The CNA denied she was planning a one- person transfer, given there was no mechanical lift in the room. CAN A stated after receiving an in-service training from LVN B she should not have left to answer a call light; and should have requested assistance from another nurse aide in the answering of the call light.
During telephone interview on 3/26/24 at 12:27 PM, the MD stated: he did not know whether the specialized wheelchair was a restraint. He had no orders for the 24- hour monitoring of the resident (Resident #1). The MD did not want to express an opinion as to whether nursing staff needed to have a staff present when anticipating a mechanical lift. The MD stated he saw Resident #1 in the ER and she was treated and returned to the facility the next day. The MD stated that Resident #1 was on blood thinners which could lead to quick bleeding if the resident had a fall.
Attempted telephone call on 3/26/24 at 2:25 PM, message left for family member to call the state surveyor.
During an observation and interview on 3/26/24 at 2:40 PM, Resident #2 was in bed trying to sleep, pressure release call light was present. The resident stated that on the day of the incident [1/30/24] she returned to her room and found Resident #1 on the floor in the room crying and blood present on the floor. Resident #2 could not remember pushing the call light to request nursing assistance during the incident.
[Record review of Resident 2's face sheet, dated 3/26/24 revealed, the resident was admitted on [DATE] with diagnoses that included: stroke, diabetes type 2, and dementia. The resident was a female; age [AGE]. RP was listed as: a family member. BIMs score of 10 dated 1/11/24.[score of 10 means moderately impaired in cognition]
During an interview on 3/26/24 at 2:45 PM, LVN B stated, she was at the nurse station on 1/30/24 and after the dinner meal CNA A came out screaming saying Resident #1 was on the floor bleeding from a fall. LVN B stated she was accompanied by LVN D and assessed the resident and called 911. LVN B's assessment revealed the resident was on the floor with a puddle of blood, she was crying. LVN B stated first aid was applied, pressure to the forehead, until EMS arrived. The resident returned the next day. LVN B notified the MD and tried to notify the RP. LVN B stated, I have no clue how the fall happened. LVN B stated, if a Hoyer lift is anticipated, the nurse aides should arrive together to assess and assist each other .also the nurse aide should stay with the resident until the Hoyer lift is brought to the room by another nurse aide. LVN B stated, I have no idea why nurse practice was not followed when a Hoyer lift was anticipated for Resident (#1) by CNA A. I told her (CNA A) after the incident not to leave a resident by themselves when a Hoyer lift was anticipated. CNA A did not provide an explanation for failure to follow nursing practice. LVN B stated that she received training on abuse and neglect and fall prevention; which included monitoring of residents when a mechanical lift was anticipated and done.
During an interview on 3/26/24 at 3:07 PM, the Rehab Director stated, Resident #1 was fitted for a customized innovative W/C which was not a restraint about 2-3 years ago. The Rehab Director stated, the said chair had a cushion and was usually angled at 20 degrees. The Rehab Director stated that Resident #1 has the freedom to move forward and has core strength to fall from the chair forward. The Rehab Director stated that I have always seen two nurse aides when anticipating or initiating a Hoyer lift. When Resident #1 was in therapy we never left her alone because we have seen her in therapy sessions moving forward with her core strength which shows the chair is not a restraint. The Rehab Director stated that at the time of the incident the resident was not getting therapy. The Rehab Director stated, after the incident (01/30/24) the RP was notified to initiate PT or OT but the RP refused. The Rehab Director stated the RP's latter refusal could prevent Resident #1 receiving therapy to improve mobility and transfer.
During an interview on 3/27/24 at 10:15 AM, the Administrator stated: the fall was unwitnessed and the findings were unfounded. The Administrator stated her investigation revealed that CNA A left Resident #1 in her room to attend to a call light. The W/C was secured, and the resident was calm. The Administrator stated, CNA A felt the resident was safe to be left in the room unsupervised. The Administrator stated there was no neglect because CNA A ensured the resident was safe before answering the call light. The Administrator stated the incident was a past event because: the facility initiated an in-service on fall prevention before the entrance of the state surveyors for the reported incident to the state. The in-service included, per the Administrator, the topic of Do not leave residents in room in W/C unattended. The Administrator stated, the resident has had no falls since the incident and the CP was reviewed and updated. The Administrator stated, interventions put in place for Resident #1 included: floor mat, monitoring more often, low bed, scoop mattress, and specialized wheelchair, antibiotics for a UTI, and referral to rehab services declined by the RP. The Administrator stated a resident should not be left alone when a mechanical lift was anticipated or done; and nursing aides could assist each other in answering call lights.
Observation on 3/27/24 at 11:24 AM, Resident #1 was sitting in the innovative customized W/C and attempting to lean forward by grabbing the handle bars. Nursing staff were present.
During an interview on 3/27/24 at 11:25 AM, the DON stated, Resident #1 has the upper body strength to lean forward and attempt to push herself forward to get out of the chair. The DON stated, nursing staff closely monitor Resident #1 so that she does not fall again from the W/C by thrusting herself forward.
Record review of facility's in-service training on 1/31/24 on the topics of fall prevention and abuse and neglect revealed: 30 signatures for 100 % completion rate.
Record review of facility's incident fall list for the past 90 days (January, February, and March 2024) revealed: Resident #1 only had one fall on 1/30/24.
Record review of facility's Fall Prevention policy dated 10/2022 reflected: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .to minimize the risk of falls .
Mar 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were treated with respect, dignity and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were treated with respect, dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quaility of life, recognizing each resident's individuality for 1 of 17 Residents (Resident #4) reviewed for resident rights in that:
The facility failed to promote care in a manner to enhanced dignity for Resident #4 when staff changed out her mattress with a scoop mattress.
This deficient practice could place residents at risk to feelings of poor self-esteem and decreased self-worth.
The findings were:
Record review of Resident #4's face sheet, dated 03/02/2023, revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included: history of falling, heart failure, and diabetes.
Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 14, which indicated borderline cognitive impairment.
Record review of Resident #4's care plan, revised 03/01/2023, revealed a scoop mattress was not listed as an intervention under risk for falls.
Record review of Resident #4's physcians orders, dated 03/02/2023, revealed a scoop mattress was not listed as an entered order.
During an observation and interview on 02/28/2023 at 11:45 a.m., Resident #4 stated she did not like her mattress and was not aware of why it was switched out. When Resident #4 found out it was a scoop mattress, she stated she did not know why because she had not fallen out of her bed. Resident #4 stated no one told her why it was switched and that it was switched out not long ago. Resident #4 stated she liked the mattress she had before, and she was not able to sleep on the scoop mattress.
During an interview on 03/02/2023 at 02:03 p.m., LVN B stated Resident #4 had a scoop mattress, however LVN was unable to recall for how long. She stated she had not seen anything previously on the 24 hour report that discussed when or why her mattress was switched. LVN B agreed Resident #4 was a fall risk, however, she was unable to recall a recent fall out of her bed.
During an interview on 03/02/2023 at 02:03 p.m., LVN C stated he was unable to recall how long Resident #4 had the scoop mattress. He stated he had not seen anything previously mentioned on the 24 hour report that her mattress was switched out. LVN C also had not recollection of Resident #4 falling out of her bed recently.
During an interview on 03/02/2023 at 02:03 p.m., CNA A was unable to recall when Resident #4's mattress was switched out from the previous mattress.
During an interview on 03/02/2023 at 2:31 p.m., the DON stated a scoop mattress was not implemented for Resident #4 as a fall risk. She believed with all the room changes, in the last couple of months, due to painting rooms was when Resident #4's mattress was switched out with the current scoop mattress. The DON stated she was moved around 02/09/2023 and they had to switch her to a couple of different rooms. The DON stated it was being switched out as we spoke.
During an interview on 03/02/2023 at 6:15 p.m., the DON stated the reason for the incorrect mattress was moving her to different rooms due to the facility updating rooms by painting walls and replacing floors. She stated Resident #4 was moved to room that had a scoop mattress and it was never changed out. The DON did not believe there was a potential harm to her because this resident needed help to get in and out of bed, even with a regular mattress.
During an interview on 03/02/2023 at 6:47 p.m., the Administrator was not aware of Resident #4 not having the correct mattress. He stated residents had the right to have a different mattress as long as it went alongside their level of care. He stated the potential harm, by a resident not having a mattress they liked, was loss of sleep, drowsy and maybe even behaviors.
Record review of the facility policy titled Statement of Resident Rights, dated 02/2017, revealed The community should educate, encourage, and [NAME] the rights of those we serve. Further, the community should assist a resident/patient to fully exercise their rights as applicable. [ .] Resident/Patient Rights include: [ .] 10. To participate in developing a plan of care, to refuse treatment, [ .] 22. To be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat their medical symptoms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to accurately reflect on the MDS assessment the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to accurately reflect on the MDS assessment the resident's status for one resident (#141) of 8 residents reviewed for accurate assessments in that:
The facility failed to reflect Resident #141's oxygen while at the facility on his admission MDS assessment.
This deficient practice could affect residents who receive oxygen therapy and could result in hypoxia (below normal level of oxygen in blood stream).
The findings were:
Review of Resident #141's electronic admission record dated 02/28/2023 revealed he was admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream), cellulitis (serious skin infection) of lower limb and heart failure (A progressive heart disease that affects pumping action of heart muscles).
Review of Resident #141's admission MDS assessment dated [DATE] revealed he was not coded for use of oxygen while at the facility. He scored a 15/15 on his BIMS which indicated he was cognitively intact.
Review of Resident #141's comprehensive person-centered care plan dated 02/05/2023 revealed Focus .at risk for experiencing shortness of breath .Intervention .Provide oxygen as ordered.
Review of Resident #141's Active Orders as of: 02/28/2023 revealed 02 at 2LPM via NC as needed for SOB .Start Date 02/04/2023.
Observation on 02/28/2023 at 10:30 a.m. revealed Resident #141 had oxygen infusing via nasal canula at 5L/min.
Interview on 02/28/2023 with Resident #141 revealed he had oxygen on continuously for the last ten years and while he was admitted to the facility.
Interview on 03/02/2023 at 5:52 p.m. with the DON revealed the MDS nurse was not available for interview, but that she was accountable for the nursing care at the facility and reviewed the MDS's. She stated that Resident #141 came in with oxygen and stated that the admission MDS assessment needed to reflect his oxygen use, and she did not know why it didn't. She stated accuracy of the MDS was important because it provided information for the care of the resident.
Review of the facility policy and procedure titled Comprehensive Assessments dated February 2017 revealed Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and areas of decline. The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure that a resident who needs respiratory care, inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for one resident (#141) of 2 residents reviewed for oxygen therapy in that:
The facility failed to have Resident #141's oxygen set at the correct rate as was ordered by the physician.
This deficient practice could affect residents who receive oxygen therapy and could result in hypoxia (below normal level of oxygen in blood stream).
The findings were:
Review of Resident #141's electronic admission record dated 02/28/2023 revealed he was admitted to the facility on [DATE] with diagnoses of sepsis (an infection of the blood stream), cellulitis (serious skin infection) of lower limb and heart failure (A progressive heart disease that affects pumping action of heart muscles).
Review of Resident #141's admission MDS assessment dated [DATE] revealed he was not coded for use of oxygen while at the facility. He scored a 15/15 on his BIMS which indicated he was cognitively intact.
Review of Resident #141's comprehensive person-centered care plan dated 02/05/2023 revealed Focus .at risk for experiencing shortness of breath .Intervention .Provide oxygen as ordered.
Review of Resident #141's Active Orders as of: 02/28/2023 revealed 02 at 2LPM via NC as needed for SOB .Start Date 02/04/2023.
Review of Resident #141's progress notes since his admission revealed there were no notes that addressed that he changed his own oxygen rate.
Review of the Licensed Nurse Administration Record for Resident #141 dated 02/01/2023 to 02/28/2023 revealed 02 at 2LPM via NC as needed for SOB .Start Date 02/04/2023, and none of the dates were initialed by the nursing staff which indicated Resident #141 did not use his oxygen as needed. Oxygen saturation's were checked every shift since his admission and initialed by the nurses who checked it.
Observation on 02/28/2023 at 10:30 a.m. revealed Resident #141 had oxygen infusing via nasal canula at 5L/min.
Interview on 02/28/2023 with Resident #141 revealed he had oxygen on continuously for the last ten years and while he was admitted to the facility. He stated he would turn the oxygen on and off because of the noise at times, but did not adjust his own rate. He stated it should have been at 2L.
Interview on 03/02/2023 at 5:52 p.m. with the DON revealed that she delivered a food tray to Resident #141 on 02/28/2023 and noticed his oxygen was set at 5LPM. She notified the doctor and had his rate changed. She later went in to Resident #141's room and his oxygen was set at 4.5LPM. She notified the doctor again, and had the orders changed from 2L to 5LPM. She stated the Resident adjusted his own oxygen, but had not seen him do it. When asked by the surveyor about why there were no progress notes about the behavior since he had been at the facility for almost a month and why the nurses had not brought it up since his orders were for 2LPM, she did not have an answer. She stated that Resident #141 came in with oxygen and that the nurses should have checked his oxygen rate as they also checked his oxygen saturations every shift. The DON further stated that it was important for the nurses to check the oxygen because too much or too little oxygen could result in hypoxia.
Review of the facility policy and procedure titled Oxygen Administration dated revised January 2022 revealed A resident receives oxygen therapy when there is an order by a physician .3. Obtain physician orders for oxygen administration .c. flow rate of delivery.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to ensure food was prepared in a form designed to meet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 6 residents (Resident #17) reviewed for food meeting the residents' needs, in that:
The facility failed to ensure the pureed bread was a pudding consistency as required for food served to residents who received a pureed diet.
This deficient practice could place residents at risk of dissatisfaction, poor intake, choking, and/or weight loss.
The findings included:
Record review of Resident #17's face sheet, dated 03/02/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: dementia, osteoarthritis, hemiplegia affecting left non-dominant side.
Record review of Resident #17's quarterly MDS, dated [DATE], revealed a staff assessment was conducted, instead of an interview, which indicated severe cognitive impairment.
Record review of Resident #17's physician orders, dated 03/02/2023, revealed an order dated 11/03/2022, Fortified Meal Plan diet Puree texture [ .].
Record review of the menu, dated Week 2 and served for lunch on 03/01/2023, revealed the menu for the pureed meal for residents included pureed chicken tarragon, pureed roasted new potatoes, pureed herbed green beans and pureed wheat rolls.
Record review of facility diet roster, dated 02/28/2023, revealed nine residents were on a pureed diet.
During an observation and interview on 03/01/2023 at 12:27 p.m., revealed Resident #17 attempted to eat the pureed bread and had a difficult time getting the pureed bread to slide down his throat. Resident #17 stated it was sticky in his mouth. LVN B stated there was an ongoing issue with the pureed foods being too thick. Observation of the pureed bread revealed it looked thick, clumpy and it stuck to the spoon. LVN B offered Resident #17 fluids when he stated the pureed bread was sticky. LVN B attempted to give Resident #17 a bite of another food item and Resident #17 refused, showing pureed bread still in his mouth. LVN B continued to offer more fluids to help Resident #17 swallow the pureed bread. Resident #17 refused to eat anymore of pureed bread after the first attempt.
During an interview on 03/02/2023 at 10:45 a.m., [NAME] D stated she made the pureed bread, yesterday, with milk. [NAME] D was unable to recall the consistency of the pureed bread from yesterday, however, she stated she did not use much milk when she made it.
During an interview on 03/02/2023 at 6:33 p.m., the DM stated he was aware of recipes for pureed items. He stated he remembered how to make pureed biscuits for today's lunch, however, he did not watch [NAME] D make the pureed items yesterday. The DM stated [NAME] D made the pureed items yesterday. The DM stated a potential harm to residents, in pureed items being too thick was a resident could choke.
During an interview on 03/02/2023 at 6:35 p.m., the RD stated the cook was responsible for making pureed items for each meal prepared. The RD also stated the DM was responsible for ensuring pureed items were the correct consistency. The RD stated a potential harm to residents was choking if the pureed items were too thick.
During an interview on 03/02/2023 at 6:03 p.m., the DON stated pureed items should be soft, and more like pudding and resident's should not have a hard time swallowing it. The DON, then, stated the RD, mentioned yesterday, the bread was to dry and he was working with educating dietary staff. The DON stated the cook was responsible for making pureed items. She also stated a potential harm to residents was a resident choking if the pureed items were difficult to swallow.
During an interview on 03/02/2023 at 6:44 p.m., the Administrator stated he was familiar with pureed diets needing to be easier for residents to swallow and was supposed to be the same nutrition and taste as the regular menu items. The Administrator stated the potential harm to residents was they may not like the pureed item and then refuse to eat it or they could choke.
Record review of the facility policy titled, Diet Manual, dated 10/01/2018, revealed The facility will adopt a currently accepted up-to-date manual that supports the diets served in order to ensure that all diets are served according to nutritional best practices and current standards of care.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure bedrooms measured at least 80 square feet per resident mult...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure bedrooms measured at least 80 square feet per resident multiple bedrooms and at least 100 square feet in single resident rooms for in 9 of 28 multiple resident rooms (Rooms 3, 10, 11, 12, 13, 20, 23, 24 and 28) reviewed for the 80 square feet per Resident requirement, in that:
The facility failed to ensure resident rooms 3, 10, 11, 12, 13, 20, 23, 24 and 28 measured at least 80 square feet per resident for multiple occupancy or 100 square feet per resident for single occupancy.
This deficient practice could place residents at risk of not having sufficient room to carry out activities of daily living care, or have the room furnished as they would like and place them at risk for a decreased quality of life.
The findings were:
Record review of current measurements taken by Life Safety Code revealed the following: room [ROOM NUMBER], a double occupancy, measured as 74.587 sq ft. per bed; room [ROOM NUMBER], a single occupancy, measured as 84.77 sq ft. per bed; room [ROOM NUMBER], a single occupancy, measured as 98.5 sq. ft. per bed; room [ROOM NUMBER], a triple occupancy, measured as 57.58 sq. ft. per bed; room [ROOM NUMBER], a single occupancy, measured as 97.94 sq. ft. per bed; room [ROOM NUMBER], a double occupancy, measured as 72.14 sq. ft. per bed; room [ROOM NUMBER], a double occupancy, measured as 79.91 sq. ft. per bed; room [ROOM NUMBER], a double occupancy, measured as 79.91 sq. ft. per bed; and room [ROOM NUMBER], a double occupancy, measured as 78.21 sq. ft.
Record review of the facility daily census dated 02/28/2023 revealed the following: room [ROOM NUMBER] had one occupant; room [ROOM NUMBER] had one occupant; room [ROOM NUMBER] had one occupant; room [ROOM NUMBER] had one occupant; room [ROOM NUMBER] had no occupants; room [ROOM NUMBER] had one occupant; room [ROOM NUMBER] had 2 occupants; room [ROOM NUMBER] had 2 occupants and room [ROOM NUMBER] had one occupant.
During an interview on 03/02/2023 at 6:44 p.m., the Administrator stated he wanted to continue the room waiver. The Administrator stated as long as the census permitted the facility could separate the residents into individual rooms. However, his corporate office was in the process of purchasing property for a nursing home to be built and all the residents and/or staff would move to that building. This information indicated the current facility would no longer be utilized as a nursing home at that time. The Administrator then stated they were estimated to be about 18 months away for that to occur. The Administrator stated he did not believe there was a potential harm to residents.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (83/100). Above average facility, better than most options in Texas.
- • 15% annual turnover. Excellent stability, 33 points below Texas's 48% average. Staff who stay learn residents' needs.
Concerns
- • 18 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Del Rio's CMS Rating?
CMS assigns DEL RIO NURSING AND REHABILITATION CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Del Rio Staffed?
CMS rates DEL RIO NURSING AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 15%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Del Rio?
State health inspectors documented 18 deficiencies at DEL RIO NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 1 that caused actual resident harm, 15 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Del Rio?
DEL RIO NURSING AND REHABILITATION CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility is operated by TOUCHSTONE COMMUNITIES, a chain that manages multiple nursing homes. With 60 certified beds and approximately 43 residents (about 72% occupancy), it is a smaller facility located in DEL RIO, Texas.
How Does Del Rio Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, DEL RIO NURSING AND REHABILITATION CENTER's overall rating (5 stars) is above the state average of 2.8, staff turnover (15%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Del Rio?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Del Rio Safe?
Based on CMS inspection data, DEL RIO NURSING AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Texas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Del Rio Stick Around?
Staff at DEL RIO NURSING AND REHABILITATION CENTER tend to stick around. With a turnover rate of 15%, the facility is 30 percentage points below the Texas average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Del Rio Ever Fined?
DEL RIO NURSING AND REHABILITATION CENTER has been fined $8,018 across 1 penalty action. This is below the Texas average of $33,159. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Del Rio on Any Federal Watch List?
DEL RIO NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.