Inspection Reports for San Antonio West Nursing and Rehab
636 Cupples Rd, San Antonio, TX 78237, TX, 78237
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
309% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with professional standards regarding clinical record maintenance and care documentation, specifically focusing on the accuracy and completeness of medical records for residents.
Findings
The facility failed to maintain complete and accurate clinical records for Resident #2, who was readmitted with a foley catheter but lacked corresponding foley catheter orders in the administration records. This deficiency could place residents at risk for errors in care and treatment.
Deficiencies (1)
Failed to maintain clinical records in accordance with accepted professional standards for Resident #2, specifically missing foley catheter orders in the administration record despite the resident having a foley catheter.
Report Facts
Staff signatures on in-service attendance record: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Interviewed regarding foley catheter care and documentation for Resident #2 |
| LVN C | Licensed Vocational Nurse | Interviewed about foley catheter orders, care responsibilities, and documentation |
| DON | Director of Nursing | Interviewed about facility policies and importance of foley catheter orders in administration records |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify residents or their representatives about room changes, failure to notify representatives of significant changes in residents' conditions, and failure to develop or revise comprehensive care plans for residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify Resident #1's guardian of a room change, failure to notify Resident #2's representatives of an incident involving exit-seeking behavior and police intervention, and failure to update care plans for Residents #1 and #3 to reflect current behaviors and suicidal ideation.
Findings
The facility failed to provide written notice to Resident #1's guardian prior to a room change, failed to notify Resident #2's representatives about an incident involving exit-seeking behavior requiring police intervention, and failed to update care plans for Residents #1 and #3 to reflect current behaviors and suicidal ideation. These deficiencies could place residents at risk of harm or unmet needs.
Deficiencies (3)
Failed to ensure residents had the right to receive written notice before a room or roommate change, specifically Resident #1's guardian was not notified prior to a room change on 06/16/2025.
Failed to immediately tell the resident, resident's doctor, and family member of situations affecting the resident, specifically Resident #2's representatives were not notified of police intervention due to exit-seeking behavior on 10/03/2025.
Failed to develop and revise the complete care plan within 7 days of assessment, specifically care plans for Residents #1 and #3 were not updated to include behaviors impacting safety and suicidal ideation.
Report Facts
Residents reviewed for quality of care: 11
Residents reviewed for care plans: 11
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Stated Resident #1 was moved rooms without guardian notification and described behaviors related to curtain pulling and bed stripping. |
| RN B | Registered Nurse | Documented Resident #2's exit-seeking incident and police intervention; stated he did not notify representatives. |
| DON | Director of Nursing | Provided statements regarding notification failures and care plan deficiencies for Residents #1 and #2. |
| ADMIN | Administrator | Discussed facility procedures for notification and care planning; acknowledged failures in notification and care plan updates. |
| LPN D | Licensed Practical Nurse | Worked with Resident #1 and described behaviors related to curtain pulling and bed stripping. |
| LPN E | Licensed Practical Nurse | Reported suicidal ideation for Resident #3 and initiated SBAR communication. |
| CNA F | Certified Nursing Assistant | Described Resident #3's behavior and supervision on the porch. |
| CNA G | Certified Nursing Assistant | Provided information about Resident #3's demeanor and incident on 10/05/2025. |
| SW | Social Worker | Followed up with Resident #3 after suicidal ideation incident and provided psych services. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to assess compliance with dietary and nutritional care requirements for residents, specifically focusing on ensuring residents receive food prepared in a form designed to meet individual needs.
Findings
The facility failed to ensure that Resident #1 received the prescribed therapeutic diet and that food was prepared and served in a form meeting individual resident needs. Resident #1 was served regular textured foods instead of the ordered pureed diet, posing risks of choking and aspiration. Staff interviews and record reviews revealed inconsistent adherence to dietary orders and lack of supervision during meals.
Deficiencies (1)
Failure to ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Report Facts
Residents reviewed for dietary requirements: 6
Calories per 24 hours from bolus feeding: 1000
Fluid intake via tube feeding: 501
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Interviewed regarding Resident #1's feeding and assistance | |
| DM | Dietary Manager interviewed about diet orders and kitchen staff in-service | |
| DC | Dietary Cook interviewed about diet orders and food tray compliance | |
| DA | Dietary Aide interviewed about diet orders and food tray compliance | |
| LVN B | Licensed Vocational Nurse | Interviewed about Resident #1's bolus feedings and pleasure trays |
| HN | Head Nurse | Interviewed about Resident #1's nutritional deficit and feeding concerns |
| RD | Registered Dietitian | Interviewed about feeding orders and dietary conflicts |
| RN A | Registered Nurse | Interviewed about Resident #1's feeding needs and denture status |
| LVN C | Licensed Vocational Nurse | Interviewed about Resident #1's feeding and hospice orders |
| Administrator | Interviewed about facility policy and awareness of pleasure trays |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to pressure ulcer care and pest control in the nursing facility.
Findings
The facility failed to provide appropriate pressure ulcer care for Resident #1, including failure to implement treatment orders and complete wound assessments, resulting in actual harm. Additionally, the facility failed to maintain an effective pest control program, leading to maggots being found in a resident's wound, constituting immediate jeopardy at one point.
Deficiencies (2)
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to implement treatment orders and complete wound assessments for Resident #1.
Failed to maintain an effective pest control program, resulting in maggots found in Resident #1's right heel wound.
Report Facts
Number of wounds on Resident #1: 9
Dates of wound treatment order start: 3
Date of pest control visit: 2025
Date of maggot discovery: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Treatment Nurse | Provided wound care and involved in wound assessments; observed wound care refusals and maggot removal. |
| LVN D | Licensed Vocational Nurse | Observed maggots in Resident #1's wound and notified MD; involved in wound care and documentation. |
| DON | Director of Nursing | Provided wound care, accompanied resident to hospital, and involved in wound care oversight and interviews. |
| RN K | Registered Nurse | Witnessed resident signing AMA form and involved in wound care documentation. |
| RN B | Registered Nurse | Provided wound care and documented refusals. |
| NP PP | Nurse Practitioner | Provided wound care and gave clinical opinions on wound care refusals and maggot development. |
| Administrator | Involved in pest control oversight and interviews regarding maggot incident and facility pest control program. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to maintain complete and accurate medical records for Resident #1, specifically related to treatment administration documentation.
Complaint Details
The complaint investigation found that the facility failed to document wound care treatments on three specific dates for Resident #1. Interviews revealed uncertainty about why the treatment administration record was not marked completed, with staff acknowledging the issue.
Findings
The facility failed to ensure that Resident #1's treatment administration record noted treatments on 08.13.2025, 08.18.2025, and 08.24.2025 as required by physician orders, potentially placing residents at risk of not receiving necessary care or receiving care more often than ordered.
Deficiencies (1)
Failure to maintain complete and accurate medical records for Resident #1, specifically treatment administration records not marked as completed on specified dates.
Report Facts
Dates treatments not marked completed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding wound care treatment administration and documentation failures | |
| Wound Care Nurse B | Usually performed wound care for Resident #1; absent on one day when care was performed by LVN A | |
| DON | Director of Nursing | Interviewed about treatment administration record documentation issues |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Aug 18, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with regulatory requirements related to the facility's environment, food service safety, and equipment maintenance.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, including non-functioning overhead light fixture and broken window blind in Resident #1's room. The kitchen steam table was not operating, resulting in cold food being served and incomplete food temperature logs. The facility lacked policies on documenting food temperatures and maintaining essential equipment.
Deficiencies (4)
Failed to provide Resident #1's room with a functional overhead light fixture and an unbroken window blind.
Failed to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature; steam table not operating causing cold food to be served.
Food temperature logs were incomplete, lacking documentation for multiple meals in July 2025.
Failed to maintain dietary equipment; steam table was not operating.
Report Facts
Food temperature readings: 110
Food temperature readings: 159
Food temperature readings: 92
Food temperature readings: 122
Food temperature readings: 79
Food temperature readings: 88
Food temperature readings: 81
Food temperature readings: 89
Food temperature readings: 78
Food temperature readings: 120
Food temperature readings: 80
Food temperature readings: 97
Food temperature readings: 80
Food temperature readings: 71
Food temperature readings: 70
Food temperature log missing dates: 13
Work order date: Jun 17, 2025
Steam table purchase order date: Aug 14, 2025
Inspection completion date: Aug 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Reported Resident #1's light fixture and blind issues to nursing management | |
| CNA C | Informed nurse management about broken blind and light fixture | |
| Social Worker (SW) | Observed broken blind and non-operating light fixture; noted work orders | |
| Director of Nursing (DON) | Observed deficiencies and commented on nursing practice importance | |
| Administrator | Discussed maintenance backlog and prioritization; steam table purchase | |
| Food Service Supervisor (FSS) | Reported steam table non-operation and food temperature log issues | |
| Dietician | Advised on food temperature safety and documentation; recommended interim measures | |
| [NAME] A | Kitchen staff member reporting steam table issues and food temperature efforts |
Inspection Report
Deficiencies: 3
Date: Jul 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding the maintenance and documentation of medical records for residents.
Findings
The facility failed to ensure that medical records were complete and accurately documented for 2 of 4 residents reviewed, specifically missing documentation of output and vital signs on specified dates, which could place residents at risk of not receiving needed care.
Deficiencies (3)
Failure to document Resident #2's output on 6/9/25 and 6/19/25.
Failure to document Resident #3's output on 6/9/25 and 6/19/25.
Failure to document Resident #3's complete vital signs on 6/29/25.
Report Facts
Residents reviewed for clinical records: 4
Residents with incomplete documentation: 2
Dates missing output documentation: 2
Date missing vital signs documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN E | Registered Nurse | Assessed Resident #3's vital signs on 6/29/25 and stated documentation was completed |
| DON | Director of Nursing | Expected nurses to document all resident assessments including vital signs |
| Administrator | Expected nurses to use judgment for documentation and follow facility policy |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 2, 2025
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with professional standards related to food service safety and the functional environment for residents.
Findings
The facility was found deficient in maintaining food service safety due to dead insects on ceiling light covers and a black substance on a ceiling vent in the kitchen, posing a risk of infection and food contamination. Additionally, the facility failed to provide functional bedside and overhead lighting in Resident #1's room for over 30 days, which could diminish the resident's quality of life.
Deficiencies (3)
Failed to have two overhead ceiling light covers in the cooking area free from numerous dead brown insects.
Failed to ensure the ceiling vent in the dishwashing area was free from a black substance throughout the vent.
Failed to provide Resident #1 with functional bedside and overhead lights for a minimum of 30 days.
Report Facts
Residents affected: 1
Rooms reviewed for functional environment: 16
Duration lights not working: 30
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the kitchen deficiencies and lighting issues in Resident #1's room | |
| DON | Director of Nursing | Observed kitchen deficiencies and confirmed lighting issues in Resident #1's room |
| Dietician | Interviewed regarding kitchen sanitation and unaware of deficiencies | |
| FSS | Food Service Supervisor | Interviewed regarding kitchen sanitation and acknowledged dust in ceiling vent |
| RN A | Registered Nurse | Reported work order for lighting issue and importance of lighting for resident care |
| CNA A | Certified Nursing Assistant | Reported lighting issue in Resident #1's room |
| CNA B | Certified Nursing Assistant | Reported lighting issue and resident complaints |
| Interim Maintenance Director | Maintenance Director | Unaware of lighting issue and missing manual work order log |
Inspection Report
Annual Inspection
Census: 13
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulations, including resident safety and pharmaceutical services.
Findings
The facility failed to protect residents from physical abuse in the Memory Care Unit, resulting in immediate jeopardy that was later removed. Additionally, the facility failed to provide pharmaceutical services that ensured timely medication administration and proper medication storage, including expired insulins.
Deficiencies (2)
Failure to protect residents from physical abuse by other residents in the Memory Care Unit, including incidents of punching, hair pulling, and dragging.
Failure to provide pharmaceutical services including late medication administration and storage of expired insulins.
Report Facts
Residents in Memory Care Unit: 13
Late medication administration: 6
Expired insulin days: 59
Staff signatures on Abuse and Neglect in-service: 89
Staff signatures on Understanding Dementia in-service: 44
Staff signatures on PAL in-service: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN S | Nurse | Witnessed resident-to-resident abuse and provided care post-incident |
| CNA A | Certified Nursing Assistant | Witnessed resident-to-resident abuse and alerted for emergency assistance |
| LVN C | Licensed Vocational Nurse | Documented incidents of resident-to-resident abuse and worked MCU and C-hall |
| MA E | Medication Aide | Administered late medications to multiple residents |
| DON | Director of Nursing | Provided statements on staffing and expectations for medication administration |
| Administrator | Facility Administrator | Notified of immediate jeopardy and responsible for staffing corrections |
| Dr. X | Medical Director | Provided in-service training on dementia care |
| LVN Z | Licensed Vocational Nurse | Observed handling expired insulin and medication cart |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements, including resident rights, safety, care, infection control, medication management, activities, and environment.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, privacy violations, inadequate lighting, failure to prevent resident-to-resident abuse, incomplete care plans, insufficient activities and lack of a full-time activity director, improper pressure ulcer care, medication errors including late administration and expired medications, failure to maintain safe food service practices, malfunctioning wander guard alarms, and inadequate infection prevention practices.
Deficiencies (14)
Failure to ensure residents were treated with dignity and respect, including serving meals simultaneously and providing appropriate meal substitutions.
Failure to ensure resident privacy and confidentiality, including staff not knocking before entering rooms and leaving computer screens open with resident information.
Failure to provide a safe, clean, comfortable, and homelike environment, including malfunctioning dining room lighting.
Failure to protect residents from physical abuse, including an incident where Resident #83 physically battered Resident #61.
Failure to develop and implement a comprehensive person-centered care plan consistent with resident rights, including mismatched code status for Resident #5.
Failure to provide activities to meet residents' needs, including lack of a full-time activity director and inconsistent activity programming.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to offload heels and reposition residents.
Failure to ensure adequate supervision and functioning wander guard alarms to prevent elopement.
Failure to provide and implement an infection prevention and control program, including failure to follow enhanced barrier precautions.
Failure to ensure medication error rates below 5%, including late medication administration and failure to report late doses.
Failure to provide pharmaceutical services to meet residents' needs, including expired insulins and improper storage.
Failure to ensure menus meet nutritional needs, are prepared in advance, followed, updated, and reviewed by dietician, including failure to follow diet textures.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including missing discard dates, incomplete logs, and improper dress code in kitchen.
Failure to ensure nursing home area is safe, easy to use, clean and comfortable, including unsecured fencing and improper trash disposal in secured yard.
Report Facts
Medication administration opportunities: 25
Medication errors: 4
Medication error rate: 16
Residents in MCU: 13
Weight loss: 11.9
Weight loss: 10
Staff signatures: 89
Staff signatures: 44
Staff signatures: 28
Cigarette butts: 100
Expired insulin days: 59
Expired insulin days: 45
Expired insulin days: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Witnessed Resident #83 dragging Resident #61 by hair and leg; left MCU to get help during abuse incident |
| RN S | Registered Nurse | Witnessed Resident #83 dragging Resident #61; provided care during abuse incident |
| LVN J | Licensed Vocational Nurse | Left medication cart unlocked and unattended for 7 minutes |
| MA E | Medication Aide | Administered late medications; did not wear PPE during medication administration to Resident #69 |
| LVN Z | Licensed Vocational Nurse | Demonstrated expired insulin pens and vials; stated she would discard expired medications |
| CDM | Certified Dietary Manager | Revealed missing discard dates on food; unaware of missing temperature and sink logs; responsible for kitchen oversight |
| CNA F | Certified Nursing Assistant | Reported Resident #79's TV was not working; witnessed malfunctioning wander guard; reported late medication administration |
| DON | Director of Nursing | Provided multiple interviews regarding abuse incident, medication administration expectations, infection control, and staffing |
| Operations Manager | Operations Manager | Investigated abuse incident; stated no full-time Activity Director; unaware of unsecured yard fence |
| RD | Registered Dietitian | Provided interviews on diet texture compliance, nutritional interventions, and food safety |
| Resident #5 | Interviewed about code status and activity participation | |
| Resident #22 | Interviewed about activity program and bingo | |
| Resident #45 | Observed and interviewed regarding pressure ulcer care and activity participation | |
| Resident #67 | Observed and interviewed regarding pressure ulcer care and activity participation | |
| Resident #79 | Interviewed about activity preferences and TV access | |
| Resident #84 | Observed with malfunctioning wander guard | |
| Resident #61 | Victim of physical abuse by Resident #83 | |
| Resident #83 | Perpetrator of physical abuse against Resident #61 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to investigate a resident-to-resident altercation and inadequate supervision to prevent accidents and elopements involving residents.
Complaint Details
The complaint investigation involved failure to investigate a resident-to-resident altercation and inadequate supervision to prevent accidents and elopements for residents #1 and #2. The investigation found missing documentation of the abuse investigation and incidents of elopement placing residents at risk of harm.
Findings
The facility failed to maintain documentation of a thorough investigation of a resident-to-resident altercation and failed to ensure adequate supervision to prevent accidents and elopements for two residents. The facility also failed to designate a licensed administrator within 30 days after termination of the previous administrator.
Deficiencies (3)
Failed to maintain documentation that an alleged resident-to-resident abuse violation was thoroughly investigated.
Failed to ensure adequate supervision to prevent accidents and elopements for 2 residents, resulting in immediate jeopardy.
Failed to designate a licensed nursing home administrator within 30 days after termination of previous administrator.
Report Facts
Residents reviewed: 8
Residents affected: 2
Staff in-service count: 35
Days without licensed administrator: 39
Date of resident #1 altercation: Jul 21, 2024
Date of resident #1 elopement: May 25, 2024
Date of resident #2 elopement: Jun 6, 2024
BIMS scores: 14
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee B | Operations Manager / Acting Administrator | Served as administrator without license for 39 days; scheduled to take licensing exam on 2025-01-23 |
| Administrator C | Licensed Administrator | Oversaw Employee B; licensed for another facility; visited facility once or twice a week |
| Administrator A | Former Licensed Administrator | Terminated on 2024-11-08; failed to investigate resident-to-resident altercation |
| LVN F | Licensed Vocational Nurse | Interviewed regarding elopements and supervision |
| Maintenance Supervisor H | Maintenance Supervisor | Found Resident #1 at church after elopement; tested wander guard monitors |
| Medical Director | Medical Director | Aware of elopements and facility interventions |
| South Texas President | Regional Director | Oversaw facility since March 2024; aware of administrator licensing situation |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 6, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care for residents requiring dialysis and to evaluate the facility's infection prevention and control program.
Findings
The facility failed to ensure complete pre- and post-dialysis assessments for Resident #1 on multiple occasions, risking inadequate care. Additionally, the facility failed to maintain proper infection control practices during skin assessments and wound care for multiple residents, including improper hand hygiene and PPE use, potentially placing residents at risk for infection.
Deficiencies (2)
Failed to ensure Resident #1 had complete vital signs assessed prior to and after dialysis on multiple occasions.
Failed to maintain an infection prevention and control program, including improper hand hygiene and wound care practices for multiple residents.
Report Facts
Pre dialysis assessments not completed: 8
Post dialysis assessments not completed: 9
Residents affected: 7
Hand hygiene duration: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Licensed Vocational Nurse | Documented incomplete dialysis pre and post assessments for Resident #1 |
| LVN G | Licensed Vocational Nurse | Observed performing wound care and skin assessments with improper hand hygiene and PPE use |
| RN H | Registered Nurse | Provided expectations for dialysis assessments and hand hygiene practices |
| DON | Director of Nursing | Provided expectations for dialysis assessments and infection control accountability |
| Administrator | Stated expectations for hand hygiene practices |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to immediately inform the resident, physician, and family of significant changes in a resident's condition, specifically related to wound care and pressure ulcers.
Complaint Details
The complaint investigation revealed that Resident #5's wound care was inadequate, with failure to notify physicians of wound changes, resulting in worsening wounds and hospitalization. The facility was found to be out of compliance with immediate jeopardy identified on 09/17/2024 and removed on 09/19/2024.
Findings
The facility failed to notify the wound care physician, primary care physician, and resident representative of changes in Resident #5's wound, resulting in the wound becoming an unstageable pressure ulcer. The wound care physician was not timely notified of necrotic tissue and slough development, and wound care assessments and treatments were inconsistently documented. Resident #5 was hospitalized with severe infected pressure ulcers requiring surgical intervention.
Deficiencies (2)
Failure to immediately inform the resident, physician, and family of significant changes in resident's condition related to wound care.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Residents affected: 6
Wound size: 12.4
Wound size: 8
Wound size: 9
Wound size: 7
Wound size: 3
Slough percentage: 30
Eschar percentage: 10
Number of residents skin swept: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Provided wound care to Resident #5 and documented wound assessments; noted wound changes on 09/08/2024 and 09/09/2024. |
| CNA A | Certified Nursing Assistant | Provided care to Resident #5 and observed wound approximately 2 weeks prior to 09/15/2024. |
| CNA B | Certified Nursing Assistant | Observed Resident #5's wound about 3 weeks prior to 09/15/2024. |
| LVN C | Licensed Vocational Nurse | Charge nurse on 09/09/2024; received call from dialysis center about Resident #5's altered mental status. |
| Treatment Nurse | Treatment Nurse | Responsible for wound care assessments, notifying physicians and family, and providing wound care; admitted to inconsistent documentation and notification of wound changes. |
| Wound Care Physician | Physician | Assessed Resident #5's wound starting 08/12/2024; not notified timely of wound deterioration; stated wound needed debridement and earlier intervention. |
| DON | Director of Nursing | Oversaw wound care processes; stated expectation for timely notification of wound changes; acknowledged lack of notification of wound deterioration. |
| Hospital RN Z | Hospital Registered Nurse | Assessed Resident #5 upon hospital admission; documented severe wounds and need for urgent surgical intervention. |
| Resident #5's Primary Physician | Physician | Notified of Resident #5's condition; stated expectation that wound care physician be notified of wound changes. |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the use and care of feeding tubes and nursing staff competency in providing enteral nutrition to residents.
Findings
The facility failed to ensure that Resident #1 received proper care related to enteral feeding, specifically the administration of water flushes before feeding as ordered by the physician. Additionally, a licensed practical nurse (LPN F) demonstrated a lack of competency in administering enteral nutrition according to facility policy, which could place residents at risk.
Deficiencies (2)
Failed to ensure Resident #1's doctor's orders of administering water flush before initiating feeding were followed.
LPN F failed to provide water flushes for enteral nutrition before enteral formula was administered as ordered for Resident #1.
Report Facts
Water flush volume: 100
Enteral feed volume: 237
Total water flush volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Named in deficiency for failing to administer water flush before enteral feeding as ordered |
| DON | Director of Nursing | Interviewed regarding LPN F's deficiencies and staff training on enteral nutrition |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician of a significant change in condition, specifically an injury that developed into a hematoma.
Complaint Details
The complaint investigation found that the facility did not notify the physician of Resident #1's injury and subsequent hematoma on 08/08/2024. The on-call physician was not contacted in a timely manner, and documentation of the bump was missing from the 24-Hour Report. The facility staff delayed sending the resident to the hospital until 08/09/2024. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to notify Resident #1's physician of her change of condition on 08/08/2024 when an injury of unknown origin developed into a hematoma at the back of her head, resulting in a delay in medical treatment. Interviews and record reviews confirmed the injury was noted but not promptly reported to the physician, and documentation was incomplete.
Deficiencies (1)
Failure to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, specifically not notifying the physician of a hematoma on Resident #1's head.
Report Facts
Residents reviewed: 4
Physician order start date: Aug 6, 2024
Fall date: Jul 9, 2024
In-Service signatories: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Assessed Resident #1, reported bump to back of head, notified family and on-call physician but did not receive call back |
| LVN C | Licensed Vocational Nurse | Authored progress note documenting Resident #1 sent to emergency room for hematoma |
| DON | Director of Nursing | Reviewed injury reports, expected timely documentation and physician notification |
| ADM | Administrator | First heard of injury during morning meeting, requested Treatment Nurse assessment |
| DOR | Director of Rehabilitation | Noted bump on Resident #1's head and reported to nurse assigned to area |
| Treatment Nurse | Assessed Resident #1 on 08/08/2024, confirmed bump developed after initial assessment | |
| RN B | On-call Physician Group Registered Nurse | Reported no documented notes on 08/08/2024 and expectation for documentation at every contact |
| Maintenance Director | Directed to swap Resident #1's bed to a PVC stationary low bed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide routine and emergency drugs and biologicals to residents, specifically the late administration of seizure medication (Keppra) to Resident #1 on 5/10/2024.
Complaint Details
The visit was complaint-related due to Resident #1's report of late medication administration. The complaint was substantiated as the medication was administered late on 5/10/2024. The resident expressed concerns about the timing affecting seizure risk. The Director of Nursing confirmed the late administration and acknowledged prior complaints about medication timing.
Findings
The facility failed to administer Keppra to Resident #1 within the prescribed medication window on 5/10/2024, resulting in a delay of 1 hour and 31 minutes beyond the allowed time frame. Interviews and record reviews confirmed the late administration and the resident's concerns about medication timing. The Director of Nursing acknowledged the issue and noted it was caused by an agency nurse, with no seizures reported in 2024.
Deficiencies (1)
Failed to provide routine and emergency drugs and biologicals to Resident #1 by not administering Keppra within the medication window on 5/10/2024.
Report Facts
Medication administration delay: 91
Medication dosage: 7.5
Medication dosage: 10
Medication administration window: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Interviewed regarding Resident #1's seizure history and medication timing concerns |
| DON | Director of Nursing | Interviewed and confirmed late medication administration and monitoring responsibilities |
| ADON | Assistant Director of Nursing | Mentioned by DON as responsible for monitoring medication timeliness |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, treatment, and facility operations including resident care, incontinent care, and food safety.
Findings
The facility was found deficient in ensuring a neurologist appointment was made for a resident after a seizure event, proper incontinent care was provided by staff, and food was stored, prepared, and served in a sanitary manner to prevent contamination and foodborne illness.
Deficiencies (3)
Resident #61 did not receive a neurologist appointment as ordered after a seizure event on 5/13/2023.
CNA D did not clean Resident #50's meatus properly during incontinent care, wiping outward instead of inward.
The kitchen had multiple sanitation issues including oily residue on counters and stove, uncovered food with insects present, dirty trays, debris on floors, and poor cleaning schedules.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in finding for improper incontinent care |
| Administrator | Interviewed regarding failure to secure neurologist appointment | |
| Director of Nursing (DON) | Interviewed regarding scheduling failures and incontinent care | |
| Dietary Manager | Interviewed regarding kitchen sanitation issues | |
| Medical Director | Attempted phone interview regarding neurologist appointment failure |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 21, 2023
Visit Reason
The inspection was conducted as part of the annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' rights to reasonable accommodations and the implementation of comprehensive care plans, specifically focusing on Resident #4's care and safety.
Findings
The facility failed to ensure Resident #4's call light was within reach, as it was clipped to the privacy curtain, contrary to care plan interventions and facility policy. This posed a risk of residents not receiving timely care or attention. The facility also failed to implement a person-centered care plan with measurable objectives and timeframes for Resident #4.
Deficiencies (2)
Resident #4's call light was clipped out of reach onto his privacy curtain, contrary to care plan and facility policy.
Failure to implement a person-centered care plan with measurable objectives and timeframes to meet Resident #4's medical, nursing, and psychosocial needs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Interviewed regarding Resident #4's call light placement and confirmed it was clipped to the privacy curtain. |
| interim DON | Director of Nursing | Interviewed about call light placement, facility quality assurance processes, and care plan implementation. |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards, specifically focusing on the proper storage, preparation, distribution, and serving of food in the main kitchen.
Findings
The facility failed to ensure that items in the standing refrigerator were properly dated or discarded, which could place residents at risk for foodborne illness. Observations revealed multiple food items without appropriate opened, received, or use-by dates, and interviews confirmed inconsistent dating practices among staff.
Deficiencies (1)
Facility failed to ensure items in the standing refrigerator were dated or discarded accordingly, risking foodborne illness.
Report Facts
Dates observed: 7
Food Code citation: 350117
Inspection Report
Routine
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with food service safety standards, specifically regarding the proper storage, preparation, distribution, and serving of food in the main kitchen.
Findings
The facility failed to ensure that items in the standing refrigerator were properly dated or discarded, which could place residents at risk for foodborne illness. Observations revealed multiple food items without appropriate opened, received, or use-by dates, and interviews confirmed inconsistent dating practices among staff.
Deficiencies (1)
Facility failed to ensure items in the standing refrigerator were dated or discarded accordingly.
Report Facts
Date of observation: Jul 11, 2023
Date of interview: Jun 2, 2023
Food Code citation: 350117
Inspection Report
Routine
Capacity: 75
Deficiencies: 5
Date: Oct 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including timely transmission of Minimum Data Set (MDS) assessments, pharmaceutical services, medication security, nutritional adequacy of menus, and food preparation meeting individual resident needs.
Findings
The facility failed to timely transmit MDS assessments for 32 of 75 residents, had inaccurate controlled substance counts and documentation for 2 residents and medication carts, left medication carts unlocked and unattended, failed to follow menus and provide meals as ordered for several residents, and served food not prepared in the appropriate form for a resident with dysphagia.
Deficiencies (5)
Failure to electronically complete and transmit MDS assessments within required timeframes for 32 of 75 residents.
Inaccurate narcotic counts and failure to document controlled substance counts properly for Residents #18 and #22 and medication carts.
Medication cart (Hallway B Nurses Cart) left unattended and unlocked in hallway.
Failure to follow menus and provide corn tortillas as ordered for Residents #1, #45, and #59 during lunch service on 10/24/2022.
Resident #55 received a whole corn tortilla instead of pureed texture as ordered, risking choking and poor intake.
Report Facts
Residents reviewed for MDS transmission: 75
Residents with failed MDS transmission: 32
Residents affected by pharmaceutical deficiencies: 2
Medication carts reviewed for controlled substance counts: 4
Medication carts with deficiencies: 1
Residents affected by menu deficiencies: 3
Resident affected by food preparation deficiency: 1
Total licensed capacity: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Failed to accurately count medications on medication cart and signed controlled substance records improperly | |
| LVN E | Involved in narcotic count discrepancies and medication administration errors | |
| RN F | Nurse Manager | Nurse manager for hallway C, had not audited narcotic book since assuming responsibility |
| ADON A | Assistant Director of Nursing | Nurse manager for hallway B, stated narcotic book should be audited weekly |
| ADON B | Assistant Director of Nursing | Stated residents' meal trays are reviewed for accuracy but walked away when informed of pureed diet violation |
| DM H | Dietary Manager | Failed to verify accuracy of meals against meal tickets |
| Administrator | Acknowledged responsibility for ensuring meal accuracy and narcotic policies | |
| DON | Director of Nursing | Concluded interview prior to narcotic count discussion, stated medication carts should not be left unlocked |
| CNA C | Certified Nursing Assistant | Responsible for ensuring correct resident receives meal tray and setting up trays |
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