YOAKUM NURSING AND REHABILITATION CENTER
Non profit - Corporation
110 Beds
WELLSENTIAL HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
31/100
#624 of 1168 in TX
Photo by Yoakum Nursing and Rehabilitation Center
Photo by Yoakum Nursing and Rehabilitation Center
Photo by Yoakum Nursing and Rehabilitation Center
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Yoakum Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility's care and management. They rank #624 out of 1,168 nursing homes in Texas, placing them in the bottom half of facilities statewide, and #4 out of 5 in Lavaca County, meaning only one local option is better. The facility is showing signs of improvement, decreasing from 11 issues in 2024 to 9 in 2025, but it still has a troubling record, including a critical incident where a resident was found to be subjected to potential abuse. Staffing is below average with a rating of 2 out of 5, although turnover is slightly better than the state average at 44%. The facility has a concerning history of fines, totaling $13,627, which is average compared to other Texas nursing homes. Additional issues include poor food safety practices, such as serving spoiled food and employing a food service director without the necessary qualifications, which could jeopardize residents' health. While there is better RN coverage than 76% of facilities, these weaknesses highlight the need for careful consideration by families researching this home.
- Trust Score
- F
- In Texas
- #624/1168
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near Texas's 48% average. Typical for the industry.
- Penalties ✓ Good
- $13,627 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
31/100
Bottom 47%
Review needed
11 → 9 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 9 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Texas average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 44%
Near Texas avg (46%)
Typical for the industry
Federal Fines: $13,627
Below median ($33,413)
Minor penalties assessed
Chain: WELLSENTIAL HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
1 life-threatening
May 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #52) whose assessments were reviewed, in that:
Resident #52's quarterly MDS assessment incorrectly documented the resident as having received an insulin injection.
This failure could place residents at risk for inadequate care due to inaccurate assessments.
The findings were:
Record review of Resident #52's face sheet, dated 05/28/2025, revealed an admission date of 11/20/2019 with diagnoses including: Dementia (progressive cognitive decline, affecting thinking, memory, and reasoning, impacting daily life), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (elevated level of any or all fat in the blood), and anxiety disorder (a group of mental illnesses that cause constant fear and worry).
Record review of Resident #52's Physician orders and Medication administration records for March 2025 revealed an order for: Trulicity Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 mg subcutaneously one time a day every Thu related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. There was no order for insulin or record of insulin administration.
Record review of Resident #52's Significant Change MDS, dated [DATE], revealed a BIMS score of 09, indicating moderate cognitive impairment. The assessment further indicated in Section N0300. Injections, A. Insulin injections, Resident #52 received one insulin injection during the previous seven days.
During an interview on 05/29/2025 at 3:13 PM, the MDS LVN and the Regional Care Manager both stated they were unaware the medication Trulicity was not considered insulin since it was an injectable medication, and Resident #52's MDS dated [DATE] was incorrectly coded as the resident having received insulin.
During an interview on 05/30/2025 at 12:30 PM, the Administrator stated Resident #52's Significant Change MDS dated [DATE] was incorrectly marked as the resident having received insulin when the resident received the medication Trulicity, which was not insulin. The entire nursing staff was unaware of the properties of this medication and would be subsequently trained on the difference between this medication and insulin. The facility used the RAI manual in lieu of a separate policy on coding MDS.
Record review of Trulicity fact sheet, accessed on 06/05/2025, revealed, Trulicity is a non-insulin option that helps your body release the insulin it's already making.
Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.11, October 2024 revealed, N0350: Insulin. 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Coding Instructions for N0350A
o Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #29) whose comprehensive person-centered care plans were reviewed.
The facility failed to ensure that Resident #29's diagnosis of depression was a focus area in the resident's comprehensive care plan.
This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions.
The findings included:
Record review of Resident #29's face sheet dated 05/29/2025, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Schizoaffective disorder (a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania), major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest, and difficulty functioning) and dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life).
Record review of Resident #29's Significant Change MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Further review of this MDS revealed in Section I - Active Diagnoses, I5800, Depression was checked.
Record review of a note from the consultant psychiatric nurse practitioner dated 05/20/2025 revealed under Assessment/Plan the first diagnosis addressed was the resident's major depressive disorder.
Record review of Resident #29's comprehensive care plan, updated 02/06/2025, revealed the diagnosis of depression was not listed as a focus area.
During an interview on 05/29/2025 at 3:13 PM, MDS LVN C stated the diagnosis of depression was not listed as a focus area in Resident #29's comprehensive care plan and should be there. A possible reason for the omission might be because the resident was not taking any medication for the diagnosis, but the diagnosis should be listed regardless to ensure the resident received proper care.
During an interview on 05/29/2025 at 3:15 PM, the Regional Care Manager stated the diagnosis of depression was not in Resident #29's comprehensive care plan and needed to be included in the care plan.
During an interview on 05/30/2025 at 12:15 PM, the Administrator stated the diagnosis of depression should have been in Resident #29's comprehensive care plan, and there was no reason for its omission, especially since the resident had been at the facility for a long time.
Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 a resident who is incontinent of bladder recei...
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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 a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #63) reviewed for incontinent care, in that:
While providing incontinent care for Resident #63, CNA B used a back to front motion to clean Resident #63's buttocks.
This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.
The findings were:
Record review of Resident #63's face sheet, dated 05/30/2025, revealed an admission date of 04/17/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure).
Record review of Resident #'63's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating moderate impairment. Resident #63 required limited to extensive assistance and was frequently incontinent of bladder and bowel.
Review of Resident #63''s care plan, dated 05/01/2023, revealed a problem of has occasional bladder incontinence r/t not making it in time and dx of BPH. Uses a urinal at times but will not keep it in a bag. and an intervention of Clean peri-area with each incontinence episode.
Observation on 05/29/2025 at 2:30 p.m. revealed while providing incontinent care for Resident #63, CNA B wiped Resident #63's buttocks in a back to front motion.
During an interview on 05/29/2025 at 2:40 p.m. with CNA B, she confirmed she had wiped Resident #63's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility.
During an interview with the DON on 05/29/2025 at 3:00 p.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON and ADON spot check the staff while they provided care for infection control and quality of care.
Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care on 03/06/2025.
Review of facility policy, titled Incontinent care skills checklist, undated, revealed Wash from front to towards rectum, front to back, using clean stroke [ .] cleanse the entire buttock area and surrounding hip area.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
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 enact a policy regarding use and storage of foods bro...
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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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 8 residents reviewed, in that:
The facility failed to ensure the thermometer inside Resident #1's personal refrigerator was functioning properly and the staff recorded the accurate temperatures of the refrigerator for five months.
This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled.
The findings included:
Record review of Resident #1's face sheet, dated 05/27/2025, reflected the resident was a [AGE] year-old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Alzheimer's disease (the most common type of dementia, a progressive brain disorder that damages memory, thinking, and other cognitive abilities), dementia (a decline in mental abilities severe enough to interfere with daily life, and it is caused by damage to the brain), hypertension (high blood pressure), and depression (a persistent feeling of sadness, loss of interest, and changes in thinking, sleeping, eating, and acting).
Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 08 out of 15, indicating moderately impaired cognition. The resident required supervision or touching assistance with eating (helper provided verbal cues or touching/steadying assistance as resident completed activity).
Observation on 05/27/2025 at 2:30 PM revealed Resident #1 was sitting in her wheelchair in her room. The resident had a personal refrigerator, and inside the refrigerator was an analogue thermometer. The interior temperature of the refrigerator according to the thermometer was 26 degrees F. Further observation inside the refrigerator revealed an open can of soda approximately half-full. Shaking the can revealed the soda was not frozen, indicating the thermometer was not accurate.
Record review of the temperature log attached to the side of the refrigerator revealed temperatures taken for the months of January through May 2025. The temperatures ranged from 32 - 12 degrees F in January, 26 - 22 degrees F in February, 32 - 18 degrees F in March, 20 - 12 degrees F in April and 34 -12 degrees F in May 2025.
During an interview on 05/27/2025 at 2:35 PM, LVN E stated Housekeeping was responsible for recording the temperatures of the refrigerator on the temperature log.
During an interview on 05/27/2025 at 2:40 PM, the DON stated the thermometer inside Resident #1's read 26 degrees F, indicating it was not working properly, as the contents of the refrigerator were not frozen. The Housekeeping staff recorded the temperatures of this thermometer on a Temperature log placed in a document protector and posted on the left side of the refrigerator from January - May 2025 without noting the thermometer was broken and failed to bring the situation to the attention of nursing staff. She would ensure a new thermometer was placed in the refrigerator.
Observation on 05/27/2025 at 3:30 PM inside Resident #1's refrigerator revealed the new analogue thermometer read 40 degrees F, indicating the previous thermometer was broken and the refrigerator was functioning properly.
During an interview on 05/27/2025 at 3:20 PM, the Housekeeping Director and Administrator stated they understood the thermometer in Resident #1's facility was not functioning properly and had not been for several months. The facility's policy needed to be clearer, as it stated at the top of the temperature log form Resident Room or nourishment refrigerators should have temperatures 40 degrees F or lower. Housekeeping staff needed education on the proper range for refrigerator temperatures.
Record review of https://www.kitchenaid.com/pinch-of-help/major-appliances/refrigerator-temperature.html
accessed on 06/05/2025 revealed, .the ideal refrigerator temperature is around 37°F (3°C). That said, a range of 33-40°F (0-4°C) is typically considered safe for most purposes. Temperatures that fall below 33°F can freeze foods while temperatures above 40°F may contribute to food spoilage.
Record review of facility policy 02.005 Potluck Meals and Foods from Home approved 10/18/2018 revealed, Policy: Residents have a right to participate in potluck events and consume foods brought into the facility from outside sources. The facility will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. 2. The facility must ensure safe food handling techniques once the food is brought into the facility including safe reheating to 165 degrees for 15 seconds, holding cold items <41 degrees .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into con...
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Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 staff (FSS) reviewed for competency and skill sets.
The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services.
This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.
The findings included:
During an interview on 05/27/2025 at 11:20 AM, the FSS stated she was not a certified dietary manager or certified food service manager, and he did not have an associate's or higher degree in food service management or in hospitality. He did not have 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting. He had completed a course of study in food safety management that included topics integral to managing dietary operations including foodborne illness, sanitation procedures, and food purchasing/receiving, but had not yet taken the exam to become a certified dietary manager and able to apply for certification. He consulted periodically with a registered dietitian, but the dietitian was not employed by the facility full-time.
During an interview on 05/29/2025 at 3:12 PM, the HR Director stated the FSS assumed the position of FSS on 03/01/2024.
During an interview on 05/29/2025 at 3:30 PM, the Administrator stated she was aware the FSS was not a certified dietary manager, certified food manager, or met the other qualifications to serve as the Director of Food and Nutrition Services for the facility. The Administrator stated the FSS would be taking the exam to become a certified dietary manager shortly.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safe...
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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety.
1. The facility failed to discard a bag of salad mix dated 03/24/2025 containing brown and rotted leaves in the reach-in cooler.
2. The facility failed to ensure an opened bag of pinto beans in the dry storage room was properly sealed.
3. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions.
These failures could place residents at risk for food borne illness.
The findings included:
1. Observation on 05/27/2025 at 11:29 AM in the reach-in cooler revealed 5-lb. bag of salad mix with a label indicating it was received on 05/22/2025 and opened 05/23/2025. The bag was sealed and approximately 15% of the salad leaves had turned brown or were rotten.
During an interview on 05/27/2025 at 11:30 AM, the FSS stated the salad mix should have been discarded. All dietary staff were responsible for properly labeling and dating food items stored in the cooler and discarding items past their use-by dates.
2. Observation on 05/27/2025 at 11:36 AM in the dry storage room revealed a 50-lb. bag of pinto beans on a rack. The bag had been opened and was rolled over. The bag was not sealed or placed in a sealed bin or container.
During an interview 05/27/2025 at 11:37 AM the FSS stated the bag of pinto beans should have been placed in a sealed container, and failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests.
3. Observation on 05/29/2025 at 10:35 AM revealed [NAME] D used the high-speed blender to puree bread for the lunch meal for residents on a modified consistency (pureed) diet. After emptying the contents of the blender in a pan, [NAME] D took the blender to the preparation sink and rinsed the components in hot water. [NAME] D did not use hot, soapy water to wash the blender components or sanitize the components in a sink containing a sanitizing solution or use the dish machine to wash/sanitize the components.
During an interview on 05/29/2025 at 10:36 AM, [NAME] D stated she was told she just needed to rinse the blender components in very hot water, almost too hot to touch, between the preparation of different foods for residents on a pureed diet. [NAME] D stated she had not used soap or sanitizing solution for the blender components after preparing pureed roast pork, pureed sweet potatoes or pureed cauliflower.
During an interview on 05/29/2025 at 10:37 AM, the consultant RD stated utensils needed to be sanitized in the sink with sanitizing solution or in the dish machine.
During an interview on 05/29/2025 at 10:55 AM, the FSS stated the dietary staff had been trained by his predecessor, and he would ensure the staff was retrained on proper sanitizing procedures for equipment and utensils.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, O. Retail Food Protection Program Information Manual: Recommendations to Food Establishments for Serving or Selling Cut Leafy Greens. Following 24 multi-state outbreaks between 1998 and 2008, cut leafy greens was added to the definition of time/temperature for safety food requiring time-temperature control for safety (TCS). The term used in the definition includes a variety of cut lettuces and leafy greens.
Record review of facility policy 03.003 Food Storage revised 06/01/2019 reveled, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.
Record review of facility policy 04.005 Manual Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 5. Prior to washing, pre-flush or pre-scrape all equipment and multi-use utensils. When necessary, presoak to remove gross food particles and soil. 6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120°F. 7. Rinse in the second sink using clear, clean water between 120 °F and 140 °F to remove all traces of food, debris, and detergent. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170°F or above. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F. c. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time.
Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.
Feb 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
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 had the right to be free from misappro...
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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 had the right to be free from misappropriation of resident property for 2 of 3 Residents (Resident #4 and Resident #5) whose records were reviewed for misappropriation of medications.
1. Nursing staff did not follow procedures when re-ordering Ativan for Resident #4; two Ativan tabs were unaccounted for after an exchange of a 30 day blister pack between MA G and LVN A .
2. MA G failed to sign off after administering Resident #5's scheduled Ativan 0.5 MG tab.
These deficient practices could affect residents prescribed controlled medications and could result in the misappropriation of resident's medications.
The findings were:
1. Review of Resident #4's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Bipolar Disorder and Anxiety Disorder, Unspecified.
Review of Resident #4's quarterly MDS assessment, dated 12/0/24, revealed his BIMS score was 6 of 15 reflective of severe cognitive impairment and he had diagnoses of Anxiety, Depression and Bipolar and he received anti-anxiety and anti-depression medications.
Review of Resident #4's Care Plan, revised 10/18/24, revealed he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.
Review of Resident #4's consolidated physician orders for April 2024 revealed he an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to OTHER SPECIFIED ANXIETY DISORDERS.
Review of Resident #4's MAR for April 2024 revealed he received Ativan daily per physician orders.
Review of Provider Investigation Report, dated 4/30/24, read in part: Incident:
On April 23, 2024, at approximately 7:45 p.m. Administrator [name] was notified by Director of Nursing [name] that a blister pack of Ativan was not accurately accounted for in medication cart and when located at nurses' station two pills were missing from blister pack. Further review of the investigation revealed MA G and LVN A were both interviewed. MA G's interview read: Administrator and Treatment Nurse interviewed Certified Medication Aide G [name]. [name] MA G states that at approximately 9:30 a.m. on April 23, 2024, she gave her Charge Nurse, LVN A [name] a blister pack of Ativan for Resident #4 [name] with two pills in the blister pack. She states that she informed Charge Nurse that the resident had two pills left and needed to be re ordered. MA G [name] states that at 7:15 p.m. she began to count her cart with Charge Nurse, LVN H [name]. At this time LVN H [name] would not take over the cart because the blister pack of Ativan was missing from the cart. MA G [name] recalled giving the blister pack to LVN A [name] and it not being returned. Charge Nurse, LVN H, [name] began looking for it at the nurses station and it was located between a stack of papers. The blister pack was missing two pills and was empty. Charge Nurse, LVN H [name] immediately notified Director of Nursing [name]. LVN A interview read: Administrator and Treatment Nurse interviewed LVN A [name]. LVN A [name] states that at approximately 10 a.m.-12
p.m. MA G [name] brought her a blister pack of Ativan for Resident #4 [name]. LVN A [name] states that she reviewed the blister pack and it stated no refills. At that time she wrote a note to Dr. [name] to be faxed requesting refills. LVN A [name] states that when she looked at the blister pack there were no pills in the blister pack. LVN A [name] states that she put the blister pack with her fax and set it at nurses station.
Interview on 2/14/25 at 12:59 PM with MA G revealed she remembered the incident with the missing Ativan for Resident #4. She stated she pulled the card, blister pack, because she noticed there were only 2 tabs left. She took LVN A the card and let the nurse know there were only 2 tabs left. MA G stated LVN A took the card without question. MA G stated she knew she was not supposed to pull a narcotic card out of the cart under any circumstances unless another nurse verified the count with her prior to pulling it. She stated she wanted to show LVN A that she needed to re-order the Ativan for Resident #4. She stated she could have called her on the phone but did not. MA G stated she understood 2 tablets went missing and again stated she saw 2 tablets left in the Ativan card. MA G stated she did not take the 2 tablets.
Interview on 2/12/25 at 4:50 PM with the DON revealed she vaguely remembered the incident because it was after hours and the ADM took the lead with the investigation. She stated she understood 2 Ativan tabs were not accounted for Resident #4. She reiterated MA G pulled the card and gave it to LVN A. When the relieving nurse, LVN H, reported for shift, she noted the card was not in the cart and asked MA G about it. MA G reported she gave it to LVN A with 2 tabs left. The DON stated she called LVN A who reported it was at the nurses station with paperwork but stated the card had 2 remaining Ativan tabs. LVN A stated she called the PCP who reordered Resident #4's medications. Resident #4 did not miss any scheduled doses of Ativan. The DON stated the relieving LVN H found the card and it did not have the 2 tabs in question. The DON stated MA G should have never removed the card from the cart. She stated MA G should have let the nurse know Resident #4 needed a re-order for the Ativan. The DON stated checks and balances included: MA G and LVN H would sign off when all narcotics were administered from a blister pack. They would then remove the empty blister pack and they would give her the narcotic count sheet. The DON stated she would waste the card (empty blister pack) and count sheets were added to the Resident's hard chart and a copy was scanned and uploaded into the Resident's electronic Health Record. The DON stated ultimately, they were not able to determine what happened to the 2 missing Ativan tabs. She stated Resident #4 did not miss any Ativan doses.
Left VM for LVN A on 2/12/25 at 5:10 PM requesting she return the call. She did not return the call before the investigation was completed.
Left VM for LVN A on 2/13/25 at 2:13 PM requesting she return the call. She did not return the call before the investigation was completed.
Observation and interview on 2/14/25 at 9:17 AM revealed Resident #4 was lying in bed watching TV (volume very loud), eating chips. Resident #4 stated he had lived in the facility for about 2 years. He stated he received his medications regularly and had not missed any medications.
Interview on 2/14/25 at 4:34 PM with the ADM revealed she remembered the incident with the two missing Ativan tabs for Resident #4. The ADM stated she interviewed staff involved. She stated MA G pulled the Ativan card blister pack from the cart and took it to LVN A. MA G reported there were 2 tabs left in the card. During interview, LVN A stated when MA G handed her the card, she noted there were no tablets left in it. LVN A reported she noted there were no refills left so she called the doctor for a re-order. LVN A reported she left the empty card at the nurse's station. LVN H, who was scheduled for duty found the card at the nurse's station and it was empty. The ADM stated during interviews all the staff was upset and claimed they did not know what happened to the two tablets. The ADM stated they were not able to determine what happened to the two missing Ativan tablets. The ADM stated nursing staff should not have pulled the Ativan card before administering all the tablets. She stated there were processes in place for this reason, to avoid discrepancies, medication errors or diversion of medications.
2. Review of Resident #5's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia and Anxiety Disorder.
Review of Resident #5's quarterly MDS, dated [DATE], revealed staff was not able to interview him to determine BIMS score; he had a diagnoses of Bipolar and Anxiety and was receiving anti-anxiety medication.
Review of Resident #5's Care Plan, revised on 12/16/24 read: he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.
Review of Resident #5's consolidated physician orders revealed an order: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth two times a day for ANXIETY.
Review of Resident #5's MAR for February 2025 revealed he received Ativan per physician orders.
Observation and interview of MA G counting controlled medications on 2/14/25 at 1:10 PM revealed MA G pulled Resident #5's Ativan card. She compared it to the narcotic count sheet and the count was correct. However, there was no signature of the person who administered the medication. MA G stated she administered the Ativan to Resident #5 but she did not sign off when she administered it on 2/14/25 during the 9:00 AM medication pass. MA G stated it was important that she follow processes to prevent discrepancies which could lead to medication errors or diversion of medications. She stated she meant to sign off on it but was distracted and forgot.
Interview on 2/14/25 at 1:16 PM with the DON revealed anytime nursing staff did not follow processes when administering medications it could cause a medication error, discrepancy and or diversion of medications. If given incorrectly it could cause a resident to have a decline in condition. The DON stated it was important to pay attention and for staff to follow the processes per facility policy.
Review of facility policy, Medication Administration, dated 10/24/22, read in relevant part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 14. Administer medication as ordered in accordance with manufacturer specifications. 17. Sign MAR after administered. 18. If medication is a controlled substance, sign narcotic book.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 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 State Survey Agency for 1 of 11 Residents (Resident #6) who were reviewed for abuse, in that:
The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #6 alleged Resident #7 that provided unwanted sexual favors.
This deficient practice could affect any resident and could contribute to further abuse.
The findings were:
Record review of the facility policy and procedure titled, Abuse, Neglect and Exploitation dated 8/15/22, revealed in part, .Reporting of all alleged violations to the .state agency .within specified timeframe's .
1. Review of Resident #6's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Recurrent, Moderate and Schizoaffective Disorder, Depressive type.
Review of Resident #6's annual MDS assessment, dated 12/6/24, revealed his BIMS score was 3 of 15 reflective of severe cognitive impairment.
2. Review of Resident #7's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with a diagnosis unspecified Dementia.
Review of Resident #7's admission MDS assessment, dated 2/5/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment.
Review of a Provider Investigation Report, dated 2/12/25, revealed an allegation of verbal and physical aggression was investigated. Allegedly, Resident #6 slapped Resident #7 on the leg. Further review revealed Resident #6 stated he did it because Resident #7 crawls over to him in the night and provides sexual favors.
Record review of Texas Unified Licensure Information Portal (TULIP) revealed that no self-reported incident regarding allegations of sexual abuse
Interview on 2/13/25 at 11:30 AM with the DON related to the incident between Resident #6 and Resident #7 revealed both made an allegation. Resident #7 alleged that Resident #6 slapped him on the leg. Resident #6 alleged that Resident #7 would suck his [penis] at night which was not solicited or wanted. The DON stated she did not know if the allegation Resident #6 was reported because the ADM was responsible for reporting allegations of abuse to HHSC; however, she stated to her understanding both were reportable allegations of abuse.
Interview on 2/13/25 at 4:34 PM with the ADM revealed she identified during the investigation involving Resident #6 and Resident #7 there were 2 allegations that should have been reported; physical abuse which she reported and sexual abuse which she did not report. The ADM stated she incorporated both allegations into the investigation for physical aggression but should have reported and investigated each allegation separately.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 maintain an infection prevention and control program d...
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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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment, and written standards, policies, and procedures for the program, which must include, but are not limited to: . (ii) When and to whom possible incidents of communicable disease or infections should be reported, for 1 of 1 facility reviewed for infection control, in that:
The facility failed to have written standards that include when and to whom possible incidents of communicable disease or infection should be reported.
These failures could place residents at risk of a delay in identification of infectious outbreaks and lack of timely follow-up on recommended interventions to prevent harm, or impairment.
The findings included:
1. Record review of Resident #2's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, ENCEPHALOPATHY (enlargement of the brain), UNSPECIFIED MACULAR DEGENERATION (blindness over time), and GLAUCOMA (eye damage).
Record review of Resident #2's most recent quarterly MDS assessment, dated 11/13/24 revealed,
the resident's BIMS score was zero (severely cognitively impaired) and required limited assistance with mobility and transfers.
Record review of Resident #2's Order Summary Report, dated 12/13/24 revealed the following:
- Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities
every shift with order
- Skin Scraping Test one time only to rule out scabies for one day, with order date 12/13/24.
-biopsy 12/16/24 one positive for scabies
- Ivermectin Oral Tablet 3 MG, give 3 mg tablet by mouth one time only for scabies for 1 day,
with order date 12/24/24 and 12/31/24.
-permethrin 5% cream two doses 12/20/24 and 12/27/24
Record review of Resident #2's microbiology report dated 12/16/24 revealed the resident was positive for scabies.
Record review of Resident #2's comprehensive care plan dated 12/13/24 revealed the resident had a rash to the torso and was prescribed Triamcinolone Acetonide Cream 0.5 %.
2. Record review of Resident #3's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted to the facility on [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, RIGHT FEMALE BREAST CANCER, and MAJOR DEPRESSION.
Record review of Resident #3's most recent quarterly MDS assessment, dated 12/26/24 revealed,
the resident's BIMS score was 3, which indicated she was severely cognitively impaired and required extensive assistance with mobility and transfers.
Record review of Resident #3's Order Summary Report, dated 1/3/25 revealed the following:
- Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities
every shift with order
- Skin Scraping Test one time only to rule out scabies for one day, with order date 1/2/25
- permethrin 5% cream two doses 1/3/25
Record review of Resident #3's microbiology report dated 1/2/25 revealed the resident was positive for scabies.
Record review of Resident #3's comprehensive care plan dated 1/2/25 revealed the resident had Scabies and was prescribed permethrin 5% cream two doses.
During an interview on 2/11/25 at 11:46 AM, the DON (IC Preventionist) stated: the outbreak started with Resident #2 on December 16, 2024, and subsequent infection of Resident #3 was January 2, 2025 (end of scabies outbreak). The DON stated no other resident tested positive. The DON stated the treatment given for Resident #2 on 12/19/24 was permethrin 5 % cream one application neck to toe and second application one week later. DON stated the treatment for Resident #3 was permethrin 5 % cream one application neck to toe. The DON stated the spread was contained by skin assessments for all residents. The DON stated the physician orders were given for prophylactic treatment of Hall 200 and 400. The DON stated all linen in Halls 200 and 400 were removed and replaced and washed, and deep cleaning in every room was conducted by housekeeping. The DON stated that 100% training on infection control and scabies was given to the staff from the time 12/16/24-01/2/25. The DON stated that the RP/family and MD were notified for the residents that tested positive for scabies. The DON stated that scabies was not a reportable event to the local health department. The DON stated that no staff presented with positive scrapings for scabies, but staff could have received prophylactic treatment in the community during the outbreak. The DON stated that the positive residents were placed in isolation. The DON stated that no self-report to HHS was made about the scabies outbreak. The DON stated that the facility did not know the source of the scabies.
During an interview on 2/11/25 at 4:11 PM, LVN A stated she worked with Resident #3 since the resident was admitted . LVN A stated that the resident had dementia with no behaviors exhibited and nursing care involved medication administration and ADL services. Also, LVN A stated nursing care involved weekly skin assessments and daily observation of skin integrity. LVN A stated scabies was a mite that got under the skin and was contagious and formed skin clusters LVN A stated that Resident #3 had scabies and treatment involved cream and an PO (by mouth) medication. The LVN stated the MD and RP were notified. LVN A stated that HHS should have been notified because scabies was a parasite, and it could spread to other residents and cause an infection.
During an interview on 2/12/25 at 8:56 AM, LVN B stated: she did not know the source of the scabies in December 2024 and January 2025. LVN B stated the interventions put in place included: treatment for Resident #2 and Resident #3; handwashing, PPE (contact isolation), and in-service for all staff on scabies. LVN B stated the outbreak ended around 1/3/25. LVN B state preventative measures put in place were continued education on IC for staff and residents, and weekly skin assessments. LVN B stated at the time of the outbreak RPs, MD C, and families were notified of the outbreak; but did not know whether HHS was notified. LVN B stated that Resident #2 had a rash, and MD C was making rounds and assessed the rash and ordered the skin scraping which was negative. The resident had a second appointment with MD C and a procedure (biopsy) which revealed one site (middle back) positive for scabies and the other site was negative (upper middle). Regarding Resident #3, LVN B stated that her family was changing the resident and noticed a few spots on the resident's abdomen area and informed the charge nurse. LVN B stated that Resident #3 was sent out for a medical appointment the same day with MD D and skin scraping was done which revealed a positive result for scabies. LVN B was not sure about reporting requirements to HHS.
During an interview on 2/12/25 at 10:08 AM, the Housekeeping Supervisor stated: housekeeping did deep cleaning of halls 200 and 400 in the months of December 2024 and January 2025 because there were cases of scabies. The Housekeeping Supervisor stated that deep cleaning involved: clothing out of closets was washed, curtains and bed linen were washed, and surface cleaning with DC-33 (disinfectant) done in the residents' rooms.
During a telephone interview on 2/12/25 at 10:20 AM, MD E stated: there was an outbreak of scabies in the facility that started December 2024 and ended in January 2025. MD E stated the source of the scabies was likely a visitor or a staff member that brought the scabies into the facility. MD E stated that he treated the infected residents (Resident #2 and #3) with permethrin 5% cream and/or Ivermectin Oral Tablet. MD E stated that the facility put in place preventative measures which included: contact precautions, monitoring, and skin assessments.
During an interview on 2/12/25 at 11:20 AM, the Administrator stated: the timeline of confirmed cases of scabies was 12/19/24 to 1/2/25. The Administrator stated there had been no other confirmed cases based on scrapings after 1/3/25. The Administrator stated that preventative measures included: education, employees to fill out incident reports if they had scabies, IC training, Plan of Correction to capture rash and skin issues, proper IC measures and rooms were cleaned. The Administrator stated that she could not determine the source of the scabies. The Administrator stated that another preventative measure for residents was prophylactic treatment for residents in hall 200 and 400; and the halls were deep cleaned. In December 2024 and January 2025. The Administrator stated that the outbreak was reported to the MD (C), RP, and residents and families. The Administrator stated the outbreak was not reported to the local health department because it was not a reportable event. The Administrator stated the outbreak was not reported to HHS because it was not a self-report, and the source was not known.
Observation and interview on 2/11/25 at 4:30 PM, Resident #3 was sitting in a wheelchair in the dining room alert and not oriented. There were no signs of skin tears, bruises, or injury. The resident revealed no signs of itching or a rash. The resident stated that she did not want an interview with the surveyor.
Observation and interview on 2/11/25 at 4:40 PM, Resident #2 was in the secured unit. The resident was ambulatory with visual impairment. The Resident had no skin tears, bruises, or injuries present. The resident was not itching or scratching and did not have a rash. The resident stated that she received the care needed and had no complaints about care. The resident stated she could not remember having scabies. The resident stated she was not itching.
Record review of the facility's policy and procedure titled, Infection Prevention program dated 5/13/23, revealed in part, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . [Policy did not address reporting communicable diseases to HHSC.]
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 immediately inform the resident; consult with the resi...
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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 immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #1) reviewed for notification of changes, in that:
Resident #1 developed new wounds on 08/01/24 and the resident representative (RP) was not informed until 08/02/24 by facility staff.
This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences.
The findings included:
Record review of Resident #1's face sheet, dated 8/13/24, male age [AGE], reflected, the resident was admitted on [DATE] and discharge 8/2/24 to home with diagnoses that included: POSTCHOLECYSTECTOMY SYNDROME (removal of the gall bladder at admissions); CALCULUS OF KIDNEY WITH CALCULUS OF URETER (kidney stone), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE [from history of stroke], PERIPHERAL VASCULAR DISEASE, UNSPECIFIED [poor blood circulation], COLOSTOMY STATUS, UNSPECIFIED OSTEOARTHRITIS [weak bones]. RP (responsible party) was listed as: a family member.
Record review of Resident #1's Significant Change (weight loss) MDS (minimum data set), dated 7/30/24, reflected: A BIMS (brief interview of mental status) Score was 8 meaning (moderate impairment); and the ADLs (activities of daily living) reflected : B/B (bowel and bladder)- and Resident #1 had a colostomy and was incontinent for urine. Transfer was mechanical lift for Resident #1. Bed Mobility was total assist and the ROM (range of motion) was total; to upper and lower.
Record review of Resident #1's CP (care plan), undated, reflected: Resident#1 had the potential for pressure ulcer development related to immobility and history of CVA (cerebrovascular accident) Hemiplegia, and Hemiparesis (stroke). Resident #1 has the potential for pressure ulcer development related to Immobility: and a history of CVA Hemiplegia, and Hemiparesis (stroke).
Record review of Resident #1's Wound Physician Assessments, dated below, reflected:
7/8/24: Right Second Toe: measurements: 7 (L) X 7 (W) X 0.1 (D).
7/25/24: Right Second Toe: measurements: .6X 6X.1. Left lateral leg 4X4X no depth (dead tissue).
8/1/24: Right second Toe: measurements .6X.6X Depth (not measurable) (dead tissue and narcosis) Left lateral measurements:4X4X (Depth) not measurable Buttocks 4.5X2.5X0.1 Right heel 3.5X3.0XDepth (not measurable) (necrosis).
During an interview on 8/13/24 at 10:29 AM, LVN A stated: on 8/1/24 the Wound Care Specialist identified left buttocks (8/1/24) wound, left lateral leg (7/25/24) wound and right second toe (7/18/24). LVN A stated the resident was not admitted with any wounds. LVN A stated that the wounds developed because of Resident's diabetes, stroke, and poor blood circulation. Resident could not move his left lateral leg (side of stroke). LVN A stated the wounds were All arterial wounds. LVN A stated the wounds were unavoidable because of the resident's comorbidities and declining health. LVN A stated the resident did not want to be in the nursing home and refused to eat. LVN A stated that PT (physical therapy), SP (speech therapy) and OT (occupational therapy) were all working with the resident to encourage eating, strength building, and mobility. LVN A stated that she had no information as to whether the RP was notified on 08/01/24 when Resident #1 was found to have developed new wounds.
During an interview on 6/13/24 at 1:19 PM, LVN B stated: the resident (Resident #1) was developing wounds due to not eating, poor vascular circulation, diabetes, dementia, and refused care (not wanting to leave his bed) LVN B stated she kept the RP verbally informed but may not have documented the 8/1/24 communications with the RP. LVN B stated that RP was informed on 7/25/24 about the new arterial left lateral leg wound. LVN B stated she did not know the reason the RP wanted to discharge the resident home.
During an interview on 8/13/24 at 1:41 PM, NA C stated: she provided bed baths to the resident (Resident #1) in the month of July 2024. NA C stated that part of giving a bed bath was documenting any wounds in the POC (point of care used by nurse aides to document activities of daily living)). NA C stated that she saw a wound on the Resident #1's buttocks and on his leg in July 2024. NA C stated, I did not know I had to tell the nurse about the wounds I saw except to document in POC. NA C stated that she often saw the RP present in the resident's room. NA C stated that as part of HIPAA she did not communicate to the RP about the wounds she saw.
During an interview on 8/13/24 at 1:55 PM, LVN D stated: she provided nursing care to Resident #1 which included: medication administration, monitoring, vital signs and assessments every day, and coordination of care. LVN D stated that the RP was present almost every day. LVN D stated she kept the RP informed about the resident's refusal not to eat and the loss of weight and the interventions attempted by the physician. LVN D stated that the verbal communications about the Resident's wounds were not documented. LVN stated that it (new wounds) needed to be documented otherwise it didn't happen.
During an interview on 8/13/24 at 2:19 PM, the DON stated: Resident #1 refused to eat, and interventions included: referral to SP, weekly weights, getting the RP involved, orders for ensure (supplement) and milkshakes. The DON stated that Resident #1 developed wounds after 30 days not eating and not wanting to get out of bed. The DON stated that the RP had been informed about the resident's decline on 7/25/24 and that the resident would accrue more wounds. The DON stated that the new wounds assessed by the Wound Care Specialist on 8/1/24, she stated she needed to check to determine whether the RP was informed on 8/1/14.
During a telephone interview on 8/13/24 at 2:57 PM, the RP stated that the facility never told her about the new wounds identified by the wound physician on 8/1/24. The RP stated the wounds were totally new and the staff never told me. The RP stated that during a mechanical lift on 7/30/24 she noticed the buttock wound.
During a telephone interview on 8/13/24 at 3:05 PM, the Wound Care Specialist stated: the resident (Resident #1) loss weight because he did not want to eat. Interventions were attempted to include IV fluids. The Wound Care Specialist. The Wound Care Specialist The Wound Care Specialist. The Wound Care Specialist, The Wound Care Specialist stated: the resident developed wounds because or arterial vascular issues, co-morbidities, and did not want to leave his bed. The Wound Care Specialist. The Wound Care Specialist stated: that his belief was that the RP was kept informed about the resident's refusal to eat and worsening condition.
During observation and interview on 8/14/24 at 8:30 AM, reflected Resident #1 was in bed in a community rehabilitation hospital. Observation revealed the resident was alert and oriented to person, place and time. The resident received by IV an antibiotic (daptomycin 500 mg); and right toe was bandaged, and there was a pressure release boot on the left leg. Resident #1 stated that the care at the nursing home was not good [but provided no specifics]. The resident stated he lost weight at the nursing home because he did not like the food and stopped eating for 30 days. The resident stated the facility offered him milkshakes and appetite stimulants and alternate diets; but he did not want to eat. The resident stated he developed wounds in the nursing home but did not know the cause of the wounds. The resident stated that he preferred to stay in bed and had a wound to his buttocks which caused him to want to be in bed. The Resident stated the facility made efforts to move him out of bed; and he did not remember about staff re-positioning him. The resident stated his right toe was amputated and he had a history of diabetes. Resident #1 stated his plan was to return home after the current hospital and rehab stays. When asked about the RP being kept informed about changes in his medical condition, Resident #1 stated: I do not think so . they were not notifying my (RP) as my condition was worsening.
Record review of facility's Resident Rights policy dated 10/24/22 reflected: .The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to make decision making capacities.
After exit on 8/14/24, the facility provided by email Resident #1's Weekly Wound Progress Note authored by LVN B which reflected resident developed new wounds on 08/01/2024 and the RP was notified on 08/02/2024 00:00 (midnight).
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans, in that:
Resident #1's care plan, undated, did not indicate that Resident #1 was on a regular diet consisting of mechanical soft texture and regular liquids as of 6/18/2024. Resident #1's care plan inaccurately indicated Resident #1 was NPO status, onset date 05/29/2024.
This deficient practice could affect residents who had a diet order change by serving a resident the wrong diet.
The findings included:
Record review of Resident #1's face sheet, undated, reflected Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage (type of bleeding in which a collection of blood gathers between parts of the brain usually caused by a severe head injury) and dysphagia (difficulty speaking).
Record review of Resident #1's admission MDS assessment, dated 06/03/2024, reflected Resident #1 had a BIMS score of 8, indicating moderate cognitive impairment.
Record review of Resident #1's June 2024 administration record, reflected Resident #1 had an enteral feed order: six times a day for provide 2130kcal, 91g pro, 2280ml total water [brand name] 1.5 bolus feeding x 6 cans/day + 100ml flush before and after q feed, start date 06/03/2024 and discontinued date, 06/19/2024. Resident #1 had an enteral feed order: three times a day bolus 2 cans of [brand name] 1.5 after meals if PO intake is < 50%, start date 06/19/2024.
Record review of Resident #1's physician order summary for June 2024, reflected Resident #1 had an order for regular diet: mechanical soft texture and regular liquids, start date 06/18/2024.
Record review of Resident #1's nutrition/dietary note, dated 06/19/2024, reflected, Diet: regular diet, mech soft texture, regular liquids. Noted diet started 06/18/2024 per ST recommendations. PO intake 75%-100% no supplements ordered.
Record review of Resident #1's care plan, undated, reflected Resident #1 has a care plan [Resident #1 first name] has a swallowing problem r/t dysphagia. He is NPO and received g-tube feedings, dated initiated 06/12/2024. The goal of the care plan stated, the resident will maintain weight and nutritional balance through the review date, dated initiated, 06/12/2024 and target date, 09/10/2024.
Record review of Resident #1's weights revealed Resident weighed 157.4 on 05/29/2024 and 159.0 on 08/05/2024 indicating Resident #1 had not lost weight.
During an interview with Resident #1, 08/07/2024 at 10:00 a.m., Resident #1 revealed he had been receiving food and medication orally since sometime in June.
During an interview with LVN A, 08/07/2024 at 12:29 p.m., LVN A stated she was the Charge Nurse for Resident #1 and Resident #1 ate meals by mouth and was administered medications by mouth. LVN A stated Resident #1 had an order for bolus feeding if Resident #1 ate less than 50% but he has not needed that in months. LVN A stated the accuracy of a resident's care plan was important because It is what we go by to provide proper care for each resident.
During an interview with MDS LVN B, 08/07/2024 at 1:51 p.m., MDS LVN B stated resident care plans should be updated whenever something happens like a fall, bruise, medication change, behavior or anything that is a change. MDS LVN B said the accuracy of resident care plans was important so staff can see what the plan of care is for the resident and so staff know how to care for the resident. MDS LVN B said a resident's care plan that was inaccurate could cause harm by injury or death.
During an interview with MDS LVN A, 08/07/2024 at 2:03 p.m., MDS LVN A revealed Resident #1 was not NPO and stated Resident #1 was eating and drinking orally. MDS LVN A revealed she and another MDS Nurse were responsible for initiating a resident care plan upon admission and the nurse managers assist with updating the care plans during the start-up morning meeting. MDS LVN A stated care plans should be updated daily, if there are any changes and MDS LVN A stated the accuracy of the resident care plan was important because it is for everyone to see how to care for a resident and what to do. MDS LVN A stated Resident #1's NPO care plan could have potentially caused Resident #1 to not get his meals, nutrition and fluids.
During an interview with the DON, 08/07/2024 at 2:45 p.m., the DON stated the nursing team checked resident orders every morning and resident care plans should have been updated by the MDS nurses or ADONs. The DON stated the accuracy of the care plans was important because it is our plan of care for the patient and if anyone needs to know how to care for the patient, they can check the care plan. The DON stated the MDS nurses had received training on care plans annually and stated, we just had an all-day training on care plans last week in a regional training.
Record review of facility policy titled Comprehensive Care Plans, date implemented 10/24/2022, reflected it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Jun 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · 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 the residents' right to be free from abuse for ...
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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 the residents' right to be free from abuse for one (Resident #1) of 7 residents reviewed for abuse.
The facility failed to prevent Resident #1 from being abused when a rubber band was discovered wrapped 4-5 times around the shaft of his penis on 6/07/2024 at approximately 2:00 AM.
The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on 06/07/24 and ended on 06/08/24. The facility had corrected the non-compliance before the state's investigation began on 6/08/2024 8:00 AM.
This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.
The findings included:
Record review of the admission Record, dated 6/09/2024, reflected Resident #1 was a [AGE] year-old male originally admitted on [DATE].
Record review of the quarterly MDS assessment, dated 3/27/2024, reflected Resident #1 had a BIMS summary score of 3, indicative of severe cognitive impairment. Under section E - Behavior, Resident #1 was documented with a lack of behavioral symptoms: did not exhibit the behavior of rejection of care; did not exhibit physical behavioral symptoms directed toward others. Under section GG - Functional Abilities and Goals, Resident #1 was documented as impairment on one side of both upper and lower extremities; Resident #1 routinely used a wheelchair for mobility; Resident #1 was coded as dependent for eating, oral hygiene, toileting hygiene, shower/bathe self. Resident #1 was coded as dependent in the following activities: lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying transition, lying to sitting on one side transition, chair/bed-to-chair transfer. Resident #1 was coded as dependent in the following activities: wheel 50 feet with two turns, wheel 150 feet. Under section H - Bladder and Bowel, Resident #1 was coded as always incontinent of bowel and bladder and was not utilizing a toileting program to manage continence. Resident #1's primary medical condition category that best described the primary reason for admission was coded as medically complex conditions related to unspecified dementia without behavioral disturbance. Other active diagnoses included diabetes mellitus, hemiplegia or hemiparesis [weakness to one side of the body], seizure disorder or epilepsy, contractures [permanent tightening of the muscles, tendons, skin and surrounding tissues that causes the joints to shorten and stiffen] : right hand, left and right knee, left and right hip, and right elbow. Resident #1 was coded as unable to answer, Have you had pain or hurting at any time in the last 5 days? Under section M - skin conditions, Resident #1 had a clinical assessment that determined he was a risk of developing pressure ulcers/injuries.
Record review of the Care Plan reflected Resident #1 had a focus area of [Resident #1] was subjected to allegations of abuse as evidenced by a rubber band found wrapped around penis with a date initiated of 6/07/2024, and a revision on 6/08/2024. Interventions included the following: administer clobetasol [potent corticosteroid topical treatment for inflammation and pain] and solumedrol [intramuscular corticosteroid that reduces inflammation, pain, swelling, redness, heat]; apply ice packs; monitor and provide patient with as needed pain medication; monitor for swelling and follow orders; monitor penis for change in condition; monitor for urinary output; notify the medical doctor of any further complications/new developments of adverse effects. Further focus areas included: [Resident #1] was passive and receives one-on-one visits . with a revision on 1/25/2022; [Resident #1] had an ADL self-care performance deficit related to .confusion, hemiplegia . with a revision date of 4/20/2021. Interventions included the following: totally dependent on staff to provide shower and or bed bath; totally dependent on staff for repositioning and turning in bed; totally dependent on staff for dressing; extensive to total assistance by staff to eat; totally dependent on staff for personal hygiene and oral care; incontinent of bowel and bladder causing Resident #1 to be totally dependent on staff for toilet use; required mechanical Hoyer lift with 2 staff for transfers. Additional focus areas, [Resident #1] had limited physical mobility related to contractures and stroke, with a revision date of 3/29/2024. [Resident #1] had a history of stroke affecting cognition, communication ability and right sided hemiplegia with a revision date of 11/07/2018. [Resident #1] had bowel/bladder incontinence related to cognitive impairment diagnosis of dementia with a revision date of 4/20/2021. Interventions included the following: use disposable briefs, change every 2 hours, and as needed; check every 2 hours and as required for incontinence.
Record review of the Nurses Note, authored by RN D dated 6/07/2024 at 3:21 AM reflected, called to Residents Room by [CNA B]; found resident with rubber band wrapped around shaft of penis 4 to 5 times. Thick rubber band constricting resident from urinating .unable to remove rubber band by hand; had to use scissors to cut [rubber band] off; upon release resident started urinating large amount of urine . Resident #1's responsible party was left a message regarding the incident. NP I was notified as she was on-call for MD H. Resident #1 was administered 1000 milligrams of Tylenol [a medication used to treat fever, pain and inflammation].
Record review of Nurses Note, authored by RN C late entry for 6/7/2024 at 2:00 AM reflected, initiation of incident report and notification of the abuse coordinator. RN C reassessed Resident #1 an hour after initial incident and noted no signs or symptoms of discomfort and penis noted to not be as swollen. RN C documented urination and bowel movement between discovery of the incident and the reassessment at 3:00 AM.
In an observation on 6/08/2024 at 9:40 AM, revealed Resident #1 was lying supine in bed, with the head of bed elevated 30-45 degrees, with the linens pulled up to axillae [arm pit]. Resident #1 had his eyes open but did not respond to verbal stimuli. Resident #1 did not maintain eye contact or tract movement with his eyes. Resident #1 appeared awake but was not responsive to the surveyor. He exhibited slow deep breaths, and a relaxed body and facial expression with no overt signs of distress.
In an interview on 6/08/2024 at 11:00 AM, NA A stated she was the staff member responsible for providing care to Resident #1 on the 6A-6P shift on Thursday 6/06/2024. NA A stated she had been working at the facility for almost 6 months so far. NA A stated she had no other interventions she knew of to make caring for Resident #1 easier. NA A stated that Resident #1 was easy to care for; he was incontinent of bowel and bladder; and could not really converse, he would just repeat back what he heard [echolalia]. NA A stated she was new and had not yet learned how to document in the electronic health record, so that other staff would enter her tasks as completed for her. NA A stated she had provided him a shower after lunch but was unsure of the time. NA A stated that during the shower Resident #1 was incontinent of bowel and bladder. NA A stated at that time there was no rubber band around his penis. NA A stated she did not know how the rubber band got around Resident #1's penis. NA A stated she did not believe that Resident #1 would be able to do that himself. NA A stated that after showering Resident #1, she had an in-service that took approximately half an hour and then she had her 30-minute lunch break at 2:40 PM. Upon returning from lunch [approximately 3:15 PM], it was then time to assist Resident #1 to the dining room for dinner. [Subsequent interviews with more tenured staff indicate that seating for the evening meal starts no earlier than 4:30 PM.] NA A stated she was not the person that assisted Resident #1 to return to his room after dinner, or assist him from his wheelchair to bed, which was his known preference. NA A stated she was assisting Resident #2 after dining and noted that Resident #1 was in bed at the end of her shift. NA A stated she did not know who put Resident #1 to bed the evening of 6/06/2024. NA A stated she assumed that whoever had assisted Resident #1 to bed had also provided incontinence checks to Resident #1 as that task was supposed to be done before the end of the shift as per facility practice. NA A stated she left the floor at approximately 6:10-6:15 PM the evening of 6/06/2024. NA A stated the last time she provided any care to Resident #1 was when she showered him, and during that shower Resident #1 had a bowel movement and was incontinent of urine in the shower.
In an interview on 6/08/2024 at 11:20 AM, the DON stated as she was walking by, she saw Resident #1 was sliding down his wheelchair in his room after dinner on 6/06/2024. The DON stated she called out to CNA F to assist her with getting Resident #1 repositioned from his wheelchair on to his bed. The DON stated she and CNA F used a mechanical lift to place Resident #1 on the bed, on top of the fitted sheet without providing an incontinence check. The DON stated she expected the person assigned to provide care for Resident #1 to check for incontinence and assist Resident #1 into his night clothes before the end of the shift. The DON stated that would have been NA A on the 6A-6P shift on 6/06/2024. The DON stated, It was pushing close to the end of shift, maybe 5:50 to 6 o'clock [in the evening] when we [the DON and CNA F] assisted [Resident #1] to the bed .
In a joint interview on 6/08/2023 at 12:30 PM, the ADM stated she was the abuse coordinator for the facility. The ADM stated she was notified just after 2:00 or 2:30 AM on 6/07/2024 that Resident #1 had been discovered with a rubber band around his penis. The DON stated she was notified around 2:30 AM on 6/07/2024. The ADM stated that she initiated an investigation immediately by interviewing staff on site and then by telephone. The ADM stated that there were inconsistencies in the explanation NA A provided detailing when she provided care to Resident #1. Additionally, the DON stated it was unusual that NA A did not document any provision of care to any resident on 6/06/2024. The ADM stated that NA A indicated that CNA F was present during all provision of care to Resident #1 on 6/06/2024. This prompted the ADM to re-interview CNA F. The ADM stated that CNA F denied being asked to help NA A by NA A or any other staff on 6/06/2024. The ADM stated at this point she suspended NA A pending the outcome of the investigation. The DON stated in-service trainings were initiated with all nursing staff working the 6A-6P shift on Friday 6/07/2024 before they were allowed to work with residents. The DON stated she included non-nursing but direct care, such as habilitation therapy staff and non-direct care staff, such as laundry personnel, with that training. The DON stated she trained each on coming shift there after before they were allowed to work with residents. The DON stated she did not believe Resident #1 had the cognitive acuity or the physical dexterity to put a rubber band around his penis. The DON stated she inspected carts and nurses' station for access to rubber bands, but could not find any that would be accessible to Resident #1.
In an interview on 6/08/2024 at 2:42 PM, RN J stated she was the nurse assigned to Resident #1 on 6/06/2024 6A-6P shift. RN J stated Resident #1 can sometimes answer very simple and immediate yes/no type questions. RN J stated Resident #1 had a stroke and had cognitive deficits and only had use of one arm. RN J stated she did not believe that Resident #1 would be able to figure out how to put a rubber band around his penis and did not think he had the manual dexterity to do so. RN J stated that Resident #1 was always incontinent of bowel and bladder and needed frequent incontinent care. RN J stated she rounded on Resident #1 several times on 6/06/2024 and did not observe any overt signs of distress, abuse or neglect. RN J stated she did not perform any incontinent care or skin checks on Resident #1 that day. RN J stated Resident #1 had not displayed any subsequent signs of discomfort or distress since the rubber band was discovered.
In an interview on 6/08/2024 at 5:36 PM, RN D stated she was not the nurse assigned to Resident #1 but had been called over by CNA B at approximately 2:00 AM. RN D stated she entered the room with CNA B and RN C and observed that a rubber band had been tightly wound around Resident #1 penis. RN D stated she attempted to unwind the rubber band, but had to use scissors to release the rubber band. RN D stated Resident #1 did not appear in pain or in any distress, and that he immediately urinated.
In an interview on 06/08/2024 at 5:47 PM, RN C stated she was the nurse assigned to Resident #1. RN C stated she followed RN D and CNA B into Resident #1's room when she heard CNA B ask for assistance. RN C stated she observed a rubber band around Resident #1's penis. RN C stated it was wrapped so tightly that they were unable to remove it by hand, and it required two snips of scissors to release the rubber band. RN C stated she stayed with and assessed the resident while RN D left the room to start an incident report and make the required notifications. RN C stated once that was complete, RN C and RN D both made rounds on all residents, starting on the 300 hallway and continuing throughout the building, to assess for any other concerns of abuse or neglect on any resident.
In an interview on 6/08/2024 at 6:10 PM, CNA E stated she was assigned the area of the hallway for Resident #1 on Thursday 6/06/2024 from 6 PM to 10 PM. CNA E stated she did not see the off going aide [NA A] and no shift change report was done. CNA E stated that was not unusual, as not all CNAs talked at shift change, and even then, would only do a mini report if something significant was going on with a particular resident. CNA E stated she had assisted Resident #1's roommate, Resident #5 to bed at around 6:30 PM on Thursday 6/06/2024, when she noticed that Resident #1 was already in bed, with his night gown on, but Resident #1 still had his pants from earlier in the day on but they were pulled down lower on his hips. CNA E stated she was thankful for that because it made it easier to remove his pants and do a check of the brief to get Resident #1 ready for bed. CNA E stated she could see from the outside of the brief there was no urine, and from the back she could tell there was no feces in the brief. CNA E stated she did not open the brief to look inside. CNA E stated she did another check on Resident #1 around 8:30 PM on 6/06/2024 and again there was no bowel movement or urine visible from the outside of his brief, and she did not open the brief to look inside . CNA E stated she was not aware of the rubber band around Resident #1's penis. CNA E stated she had received in-servicing after the incident that included abuse and neglect, the correct way to perform an incontinence check and reporting change in condition requirements.
In an interview on 6/08/2024 at 6:40 PM, CNA B stated she had started her shift at 10:00 PM on Thursday 6/06/2024. CNA B checked on Resident #1 at about 11:00 PM but did not see any urine or feces in the brief from the outside. CNA B stated she did not open the brief to inspect inside it at that time. CNA B stated she next checked on Resident #1 at about 1:45 AM on 6/07/2024. CNA B stated that when she checked from the outside, Resident #1 still appeared to have no bowel movement or urine in the brief, and that prompted her to investigate further. CNA B stated she had worked at the facility long enough to know that Resident #1 was frequently incontinent of bowel and bladder, and almost always required incontinence care every 2 hours. CNA B stated one dry brief was a favor, but 2 dry briefs in a row felt like something was wrong with Resident #1. CNA B stated that when she opened the brief to check Resident #1, she found a rubber band wrapped tightly around the shaft of Resident #1's penis. CNA B stated she immediately went to get the first nurse she could find. CNA B stated Resident #1 was sleeping lightly and had not seemed distressed at any point during her shift. CNA B stated the nurses (RN D and RN C) were able to quickly get the rubber band off Resident #1 with scissors, and Resident #1 immediately started urinating a strong stream. CNA B stated as soon as Resident #1 was situated, she immediately began checking on all the residents on her workload. CNA B stated the nurses were doing full body checks and looking to see if the residents seemed bothered by anything. CNA B stated she had not worked at the facility since the incident, but had been told that she would have to complete in-service training before starting her next shift.
In an interview on 6/09/2024 at 12:35 PM, MD H stated that the on-call NP had been notified first, since he was on vacation, but he had been apprised of the situation upon his return. MD H stated that the swelling Resident #1 was still experiencing was not unexpected. MD H stated that over the next 7 to 10 days, barring any complications, the swelling and discoloration should resolve with the current conservative course of treatment. MD H stated it was good that urine was able to flow immediately, and the swelling and discomfort seemed only moderate. MD H stated if the rubber band had not been found when it was and immediately removed, the consequences could have been dire, including total loss of the penis.
In an interview on 6/9/2024 at 1:15 PM, the DON stated in-service training was initiated on 6/7/2024 at the start of the 6 AM shift with every worker on site since the incident was discovered. The DON stated the in-servicing curriculum was explicit in that nothing should be wrapped around genitalia with out a direct order from the provider. The DON stated the in-service training would change how the facility would approach incontinence checks. The DON stated that briefs would now need to be opened for the interior of the brief and skin of the perineum to be visualized. The DON stated that abuse prohibition policies were included in in-service training that was initiated in response to the incident with Resident #1. The DON stated that no staff would be allowed to work with residents until they had had the in-servicing. The DON stated any new, agency or staff pulled from a sister facility would be trained before being allowed to work with residents. The DON stated the investigation was started immediately upon discovery of the rubber band around Resident #1's penis. All residents were assessed for emotional or physical signs and symptoms of distress, abuse or mistreatment.
Record review of Abuse Prevention Program policy, updated September 2018, reflected policy statement, committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees, other residents, consultants, volunteers, agents or power of attorney, and or staff from other agencies providing services to our residents. Policies and procedures that govern .identification of occurrences, and patterns of potential mistreatment/abuse, protection of residents. Reporting of Alleged Abuse, updated September 2018, included definition of abuse as: willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Record review of Skin Assessments revealed all 29 residents on 300 hallway received assessments 6/07/2024; followed by the remaining 57 residents of the other hallways, totaling 86 residents assessed.
Record review of In-Service Sign In sheet started 6/07/2024, reflected the following topics: Abuse and Neglect prohibition and policy; Proper Incontinent Care; Changes in Condition (notify charge nurse immediately). 22 of 22 nursing staff scheduled to work on Friday 6/07/2024 were trained on 6/07/2024 prior to working with residents included: 3 of 3 day shift nurses, the Treatment Nurse, 2 of 2 MAs, 11 of 11 day shift CNAs, 2 of 2 night shift nurses, 4 of 4 night shift CNAs. 6 of 6 nursing staff not previously scheduled to work on Friday 6/07/2024, who worked on Saturday 6/08/2024 were trained on 6/08/2024 prior to working with residents included: 2 of 2 MAs, 3 of 3 day shift CNAs, and 1 of 1 night shift CNAs. 5 of 5 nursing staff not previously scheduled to work on Friday 6/07/2024 or Saturday 6/08/2024, who worked on Sunday 6/09/2024 were trained on 6/09/2024 prior to working with residents included: 3 of 3 dayshift CNAs, and 2 night shift CNAs. A total of 51 staff that included direct and non-direct care/non-Nursing Staff were trained starting on 6/07/2023 prior to the start of their shift, included the following departments: accounting, dietary, habilitation therapy, social services, business office, human resources, receptionist, housekeeping, and laundry.
In interviews starting on 6/08/2024 8:00 am through 6/09/2024 5:45 PM, 20 staff interviews indicated, if they had worked since the incident with Resident #1, they had received training prior to working with any resident. If they had not been scheduled to work yet, they had been informed they must be in-serviced prior to working with any resident. In-servicing topics included: included: abuse and neglect: definitions, signs and symptoms, reporting requirements; change in conditions; and new protocols for incontinence checks to open brief to visualize interior and residents' perineum.
Record review of Provider Investigation Report addendum received 6/7/2024 at 12:45 PM revealed ADM was notified at 2:08 AM of incident with Resident #1. ADM arrived at the facility within 15 minutes to initiate investigation.
Ad-Hoc QAPI meeting held to discuss the incident. Additionally, local police department was notified, and provided a police report number 24-3584. Facility suspended the suspected Alleged Perpetrator, NA A, prior to entrance on 6/08/2024.
Mar 2024
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 residents had the right to reside and receive service...
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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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 15 residents (Resident #75) reviewed for call light; in that:
The facility failed to ensure Resident #75's call light was with in reach.
This failure could place residents at risk of achieving independent functioning, dignity, and well being.
Findings include:
Record review of Resident #75's face sheet, dated 3/27/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), Benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), and Peripheral vascular disease (systemic disorder that involves the narrowing of peripheral blood vessels).
Record review of Resident #75 Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated intact cognition.
Review of Resident #75's Quarterly MDS, dated [DATE], reflected under section G, G0300, option # 3 which stated, the patient was unsteady on his feet and required assistance X 1.
Record review of Resident #75's care plan, dated 4/17/23, revealed Resident #75 was at risk for falls related to weakness and unsteadiness. Intervention: Be sure the residents' call light is within reach.
Observation on 3/27/24 at 10:21 a.m. revealed Resident #75's call light was not visible, and instead the call light was wrapped on the call light box on the wall.
During an interview with Resident #75 on 3/27/24 at 10:25 a.m., he stated, They always move that call light away from me.
During an interview on 3/27/2024 at 10:55 a.m, with CNA B, she stated she was the assigned nursing assistant for Resident #75, and the call light was wrapped on the wall call light box. CNA B stated, I must have forgotten to move it back to resident #75's reach when I provided incontinent care this morning. CNA B further stated the lack of accessibility of a call light could negatively affect any resident if they needed assistance.
During an interview with the DON on 3/27/24 at 11:05 a.m., the DON stated it was her expectation call lights should be within arm's length of all residents. The DON further stated the lack of a call light could possibly lead to a fall if a resident needed something.
Record review of the facility's policy titled, Call Lights, dated 10/13/22, revealed, staff will ensure the call light is within reach of the resident and secured.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
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 develop and implement a comprehensive person-centered c...
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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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were are identified in the comprehensive assessment for 1 of 15 (Resident #24) residents reviewed for comprehensive assessments, in that:
The facility failed to ensure Resident #24's care plan documented the resident was PASRR positive.
This deficient practice could place residents at risk of not receiving proper care and services related to PASRR services.
The findings were:
Record review of Resident #24's face sheet, dated 03/28/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: Mild Intellectual Disability (impairment of cognitive skills, adaptive life skills, and social skills), Bipolar disorder (Disorder with extreme mood swings that include emotional highs and lows), and Type 2 diabetes (Disorder in which the pancreas does not produce enough insulin).
Record review of Resident #24's Care Plan, dated 03/28/2024, reflected no specific listing for Resident #24 being PASRR positive.
Record review of Resident #24's Quarterly MDS, dated [DATE], reflected Resident #24 had BIMS score of 07, indicating severe cognitive impairment.
Record review of Resident #24's PASRR Evaluation, dated 08/22/23, reflected, IDD only, for Type of Assessment. Further review reflected, Yes, was marked for, To your knowledge, does the individual have a Developmental Disability other than an Intellectual Disability that manifested before the age of 22.
During an interview with the MDS nurse on 3/28/24 at 1:20 p.m., revealed she was responsible for updating the care plans. The MDS nurse stated she did not know why Resident #24's PASRR positive status was not on the resident's care plan as he was receiving services from the local health authority due to his (Mild Intellectual Disability). The MDS nurse stated that by her not updating the care plan, Resident #24 risked not having all team members on same page.
During an interview with the DON on 3/28/24 at 1:35 p.m. revealed Resident #24 was PASRR positive and it was her expectation the care provided by care planned accordingly to ensure all team members are on the same page when providing care.
Record review of the facility's policy titled, Comprehensive Care plans, dated 10/24/22, revealed, The comprehensive care plan will describe, at a minimum, the following; c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain, in accordance with accepted professional standards and pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain, in accordance with accepted professional standards and practices medical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #50), reviewed for accuracy of records, in that:
The facility failed to ensure Resident #50's diagnosis for schizoaffective disorder was listed on face sheet.
This deficient practice could place residents at risk of having misinformation about the professional care provided.
Findings include:
Record review of Resident #50's face sheet, dated 3/27/24, revealed a [AGE] year old male who was admitted to facility on 5/1/21 with diagnoses which included: Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Bell's palsy (is a condition that causes sudden weakness in the muscles on one side of the face), and Epilepsy (brain disorder that causes recurring, unprovoked seizures).
Record review of Resident 50's Quarterly MDS dated [DATE], reflected a BIMS score of 3, which indicated severe cognitive impairment, and section A.1510 option (A) was selected which indicated severe mental illness.
Record review of Resident #50's PASRR (Pre admission Screening and Resident Review) dated 8/1/23, reflected Section (C.100) Is there evidence of mental illness, yes was selected which indicated mental illness.
Record review of [Name of Company] Psychiatric Subsequent Assessment for Resident #50, dated 3/12/24 reflected treating diagnosis, schizoaffective disorder.
During an interview with the MDS nurse on 3/28/24 at 10:15 a.m., revealed she was responsible for updating face sheets with medical diagnosis. The MDS nurse stated she was unaware why the medical diagnosis for, schizoaffective disorder, was not on face sheet for Resident #50. The MDS nurse stated by the medical diagnosis not being listed on the face sheet, the resident risked not having all care providers on same page regarding medical diagnosis.
During an interview with the Administrator on 3/28/24 at 10:32 a.m., revealed it was her expectation that documentation was accurate in the medical record as lack of documentation could result in misinformation with in care providers.
Record review of the facility's policy titled, Documentation in Medical Record, dated 10/24/22, revealed, Documentation shall be accurate, relevant and complete, containing sufficient details about the residents care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services, ta...
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Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with facility assessment for 1 of 1 facility reviewed for qualified dietary staff.
The facility failed to employ a certified dietary manager.
This failure could place residents at risk of food borne illness and not receiving adequate nutrition.
The findings were:
Record Review of the undated Employee Service List, revealed the FSS with a hire date of 05/14/2000.
In an interview on 03/26/2024 at 11:00 a.m., the FSS revealed he had been hired and worked as a cook at the facility for almost 4 years. When the previous supervisor left somewhat suddenly, 25 days ago, the FSS stated he was offered the position to move into the FSS role. The FSS stated he did not have the certification or degrees as a nursing home dietary manager, so he was enrolled in the course.
In an interview on 03/26/2024 at 11:23 a.m., the Administrator stated the FSS had recently started when the previous manager left for health reasons. She further stated he was the likely candidate, so the position was offerred and he was enrolled in the course to start in May 2024.
Record review of the Dietary Manager Registration Form, provided by the facility revealed the FSS was registered on 03/13/2024 and had chosen the semester May-August to begin.
Record review of the job description for Certified Dietary Manager, provided by the facility revealed a section, Educational/Training Requirements: Graduate of a 2 or 4 year Dietary Manager's Program or is a Registered Dietician. Licensing Requirements: Successful completion of Certified Dietary Manager exam.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal (noon meal) reviewed for food and nutrition services observed in that:
The facil...
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Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal (noon meal) reviewed for food and nutrition services observed in that:
The facility failed to ensure that the lunch menu was followed
This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.
The findings were:
An observation on 03/26/2024 at 9:55 a.m., of the facility's posted weekly menu, Fall/Winter 2023, Week 2, revealed Chicken and Dumplings, Candied Carrots, Wheat Roll, and Ambrosia Deluxe were to be served for the noon meal on 03/26/2024. The posted weekly menu revealed an alternate of Roast Beef, gravy, and Cheesy Broccoli Rice. The menu revealed no indication for a substitute.
An observation and interview with the FSS on 03/26/2024 at 10:03 a.m., revealed Beef Tips, Buttered Noodles, Turnip Greens, and Pears were to be served for the noon meal. The alternate for the noon meal was Cheese Pizza and [NAME] Salad. The FSS stated he had not had a chance to change the posted menu to the current week. The FSS further revealed he kept record of substitutions logged in the kitchen however did not know he needed to post the substitutions as well.
Record review of the facility's, Fall/Winter 2023, Week 1, menu revealed Beef Tips, Buttered Noodles, Spinach, Wheat Roll, and Strawberries w/whip topping were to have been served for the lunch meal on 03/26/2024. The alternate for the Week 1 menu revealed Braised Pork Chop, Roasted New Potatoes and Cauliflower w/Red Peppers were to be available.
Record review of the facility's policy titled, Menu Planning, revised June 1, 2019, 5. Dated current menus will be posted in all dining areas.
Record review of the facility's policy titled, Menu Substitutions, revised June 1, 2019, Policy: The facility believes that a well-balanced menu, planned in advanced and served as posted, is important to the well being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interviews 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, interviews 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.
1. The facility failed to ensure that clean plastic bowls and cups were stored properly after removal from the dish machine.
2. The facility failed to ensure that expired items were discarded.
These failures could place residents at-risk for food borne illness.
The findings were:
1. An observation on 03/26/2024 at 10:35 a.m. revealed there were eight trays of bowls, each with 9 bowls, and seven trays of clear insulated plastic cups, each with 20 cups, without air-drying nets underneath the bowls and cups. A follow-up observation on 03/29/2024 at 10:07 a.m. revealed DA C washed dishes and stacked plastic bowls on trays without air-drying nets. Observed 8 trays of bowls, each with 9 bowls.
2. An observation on 3/26/2024 at 10:47 a.m. revealed 5 plastic cups of milk covered with plastic wrap, dated 3/24.
During an interview with the Food Service Supervisor (FSS) on 03/26/2024 at 10:49 a.m., the FSS stated the trays were missing air-drying nets separating the cups and bowls from the trays. The FSS stated, We have a roll of the nets in the storage room, I am not sure why we do not use it. The FSS further stated, the milk dated 3/24 should have been used on 3/24 and if not thrown away.
During an interview with DA C on 03/29/2024 at 10:09 a.m., DA C stated she saw a tray of plastic cups with air-drying nets, however stated that she was not told she needed to put air-drying nets on the trays.
During an interview with the Food Service Supervisor (FSS) on 03/29/2024 at 10:14 a.m., the FSS confirmed that the dishwashers were responsible for ensuring there was an air-drying net on all the trays to properly air-dry and store the cups and bowls. He further stated, She is PRN and came in this morning to help and I haven't had a chance to tell her.
Record review of a facility policy titled, Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment, in the Nutrition & Foodservice Policies and Procedure Manual for Long-term Care, approved October 1, 2018, revealed, 9. Air dry all equipment and utensils after sanitizing. Handle cleaned and sanitized equipment and utensils and all single-service articles in a way that protects them from contamination.
Record review of the facility's policy titled, Food Storage, in the Nutrition & Foodservice Policies and Procedure Manual for Long-term Care, revised June 1, 2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food. Open and hold cold. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to safe, clean, comfortab...
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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 had a right to safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living for 1 of 1 facility reviewed for resident rights.
The facility failed to replace bathroom lights in four resident rooms, adequately clean three bathroom ceiling vents in resident rooms, and repair bathroom wall scraps in two resident rooms.
This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.
The findings included:
During an observation on 03/25/24 from 3:25 p.m. to 3:45 p.m. with the Maintenance Director revealed the following the following:
1. Resident room [ROOM NUMBER] which was occupied had a scrap on the bathroom wall near the sink fixture which measured approximately 18x2 inches.
2. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured 12x6 inches with rust particles noted on the vent slats.
3. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.
4. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.
5. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.
6. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured approximately 12x6 inches with dust particles noted on the vent slats.
7. room [ROOM NUMBER] which was occupied had a scrap on the bathroom wall near the sink fixture which measured approximately 12x6 inches.
8. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.
9. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured 12x6 inches with dust particles noted on the vent slats.
During an interview with the Maintenance Director and Administrator on 03/26/24 at 3:50 p.m. the Administrator stated staff used the TELS work order notification system to alert the Maintenance Director of needed repairs. The Administrator stated staff were in-serviced on the use of the TELS system and she was not aware of any work order requests for the bathroom lights not working or the bathroom wall scrapes needing repair or rust on the bathroom ceiling vent. The Administrator stated Housekeeping was responsible for removal of dust from the bathroom ceiling vents. The Maintenance Director stated bathroom lights not working in resident rooms could reduce visibility for resident's safety, the bathroom wall scrapes could upset the resident family members perception of the bathroom, and not having a clean bathroom ceiling vent would affect air quality in resident rooms.
Record review of the facility's undated general orientation agenda revealed new employees were in-serviced by the Maintenance Director on the topic of work orders.
Record review of the facility's in-service training report dated 10/27/23 revealed departmental staff were in-serviced on TELS with the topic-Reporting issues in building immediately through system and not reporting directly to employee due to overlaid of issues daily.
Mar 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 4 of 4 residents (Residents #1, #2, #3, ...
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Based on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 4 of 4 residents (Residents #1, #2, #3, and #4) reviewed for dignity and respect, in that:
RN A referred to residents who required assistance with dining as feeders within the hearing of residents.
This deficient practice could place residents at risk of psychosocial harm due to diminished self-image.
The findings were:
Observation on 02/27/2024 at 11:40 a.m. revealed RN A was sitting at a dining table with unidentified Residents #1, #2, #3, and #4, two CNAs, and one Medication Aide. RN A was sitting between two residents who require assistance with dining. RN A waved her arm to indicate the residents at the table and stated, These are all feeders in reference to the residents.
During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/27/2024 at 11:40 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits.
During an interview with the DON on 02/27/2024 at 1:00 p.m., the DON stated she would have chosen a more appropriate word in reference to residents who require assistance with dining and that she has provided training to staff regarding dignity and respect.
During an interview with RN A on 02/27/2024 at 4:30 p.m., RN A stated she could have chosen more respectful phrasing and that she meant no disrespect toward the residents.
During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/27/2024 at 4:55 p.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits.
During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/28/2024 at 11:45 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits.
During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/29/2024 at 11:55 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits.
During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 03/01/2024 at 11:45 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits.
During an interview with the Administrator on 03/01/2024 at 11:45 a.m., the Administrator stated that she had begun in-service training regarding maintaining respect and dignity while speaking to and about residents.
Record review of the facility policy, Maintaining Resident Dignity During Mealtimes, dated 01/13/2023, revealed, All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.
Feb 2023
1 deficiency
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, in that:
1. There were seven one-gallon containers of milk that had been opened and were without labels indicating the dates opened.
2. There were six one-lb. containers of strawberries that all contained rotten and moldy berries.
3. There was rust and debris on the table-top can opener.
4. There was a carton of mashed potato pearls that had been opened and was not properly sealed.
These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.
The findings included:
1. Observation on 01/31/2023 at 9:30 AM in the cooler used to store milk revealed seven one-gallon containers of milk. Six of the gallons were whole milk, of which 2 had a best by date of 2/02/23, two had a best by date of 2/09/2023 and two had a best by date of 2/14/2023. One gallon was 2% milk with a best by date of 2/01/2023. All seven gallons of milk had been opened and were ½ to ¾ full. There was no date on any of the containers of milk indicating the date they were opened.
Interview on 01/31/2023 at 9:33 AM with the FSS revealed all the milk had been received the previous day (Monday, 01/30/2023) because that was when they received their milk delivery. The FSS confirmed there were no dates indicating when the milk containers had been opened. When asked why several containers of the same product had been opened and were partially full, the FSS said sometimes nursing staff came in and grabbed a new container without seeing that one had already been opened. The FSS stated she knew it was important to indicate the date on the containers that the milk was opened regardless of the best by date because the milk started to deteriorate from that time. The FSS further stated that whoever opened the milk was responsible for dating it, and all dietary employees were trained on that during orientation and throughout the year.
2. Observation on 01/31/2023 at 9:40 AM of the reach-in produce cooler revealed six one-lb. containers of fresh strawberries. All six containers contained rotten and moldy berries and removing them from the cooler resulted in red liquid draining to the floor. The labels on the containers of strawberries indicated they had been received on 01/23/2023.
Interview on 01/31/2023 at 9:42 AM with the FSS confirmed the majority of the strawberries were rotten or had mold on them and were not fit for service. The FSS stated she hadn't had an opportunity to inspect them for quality and remove product that had gone bad.
3. Observation on 01/31/2023 at 10:03 AM revealed that the blade of the table-top can opener had a buildup of debris. The debris was black, brown and off-white in color.
Interview on 01/31/2023 at 10:03 AM with the FSS confirmed the presence of the buildup of debris on the can opener blade, and the FSS also noted there was rust on the blade. When asked who was responsible for cleaning the can opener blade, the FSS responded that it was on the cooks' list to clean daily, and that both she and the consultant dietitian do in-services on kitchen sanitation.
4. Observation on 02/02/2023 at 10:30 AM in the kitchen revealed a 3.5 lb. cardboard carton of mashed potato pearls on a shelf above the preparation table. The carton (similar to a cardboard milk carton) had been opened and was not properly sealed in a zip top bag or another similar enclosed container. The date written on the container was 01/25/2023.
Interview on 02/02/2023 at 10:30 AM with the FSS confirmed the carton of mashed potato pearls was not properly sealed. The FSS further stated it was important that food items be sealed to maintain product quality, prevent cross contamination and potential pest infestation.
Review of the facility's policy 03.003 Food Storage revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, Federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.
Review of the facility's policy 04.009 Can Opener dated 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. Procedure: 1. Hand held or table top. A. Remove can opener shank from base. B. Wash shank in sink with warm water and detergent or in the dishwasher. C. Give close attention to the blade and moving parts. D. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. F. Air dry. G. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. H. Rinse with clean cloth soaked in clear hot water.
Review of the facility's Daily Cleaning Schedule, Nutrition & Foodservice Policies & Procedures Manual, 2018, Section 4-8, revealed: Item: Can Opener. When: After Each use.
Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and:
(1) The day the original container is opened in the food establishment shall be counted as Day 1; and
(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.
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
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below Texas's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s). Review inspection reports carefully.
- • 21 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $13,627 in fines. Above average for Texas. Some compliance problems on record.
- • Grade F (31/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Yoakum's CMS Rating?
CMS assigns YOAKUM NURSING AND REHABILITATION CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Yoakum Staffed?
CMS rates YOAKUM 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 44%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Yoakum?
State health inspectors documented 21 deficiencies at YOAKUM NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 20 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Yoakum?
YOAKUM NURSING AND REHABILITATION CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by WELLSENTIAL HEALTH, a chain that manages multiple nursing homes. With 110 certified beds and approximately 84 residents (about 76% occupancy), it is a mid-sized facility located in YOAKUM, Texas.
How Does Yoakum Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, YOAKUM NURSING AND REHABILITATION CENTER's overall rating (3 stars) is above the state average of 2.8, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Yoakum?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Yoakum Safe?
Based on CMS inspection data, YOAKUM NURSING AND REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Yoakum Stick Around?
YOAKUM NURSING AND REHABILITATION CENTER has a staff turnover rate of 44%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Yoakum Ever Fined?
YOAKUM NURSING AND REHABILITATION CENTER has been fined $13,627 across 1 penalty action. This is below the Texas average of $33,215. 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 Yoakum on Any Federal Watch List?
YOAKUM 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.