Advanced Rehabilitation & Healthcare Of Live Oak
Inspection history, citations, penalties and survey trends for this long-term care facility in Live Oak, Texas.
- Location
- 8221 Palisades Drive, Live Oak, Texas 78233
- CMS Provider Number
- 675437
- Inspections on file
- 51
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Advanced Rehabilitation & Healthcare Of Live Oak during CMS and state inspections, most recent first.
A registered nurse did not identify or document a deep tissue injury on a resident's left heel during the admission assessment, despite hospital records indicating a pressure ulcer. The wound was later discovered by the Wound Treatment Nurse, who initiated treatment. The nurse expressed uncertainty about recognizing certain skin concerns and did not notify the physician for treatment orders at the time of admission, leading to a deficiency in ensuring staff competency in skin assessments.
A CNA did not wear a gown while providing direct care to a resident with a Foley catheter who was on enhanced barrier precautions, despite facility policy, care plan, and physician orders requiring gown and glove use. The resident confirmed that staff typically did not wear gowns during care, and the CNA acknowledged awareness of the EBP requirements. The DON confirmed staff training and expectations for EBP compliance.
The facility did not consistently distribute mail to residents on Saturdays, as reported by a group of residents and confirmed by staff interviews. Although a receptionist was present on weekends and delivered packages, regular mail was often left unsorted in the Business Office, leading to delays in residents receiving their correspondence.
Three residents were found with unsafe items in their rooms, including nail clippers, tweezers, sharp scissors, a disposable razor, and an all-purpose cleaner. Staff interviews revealed inconsistent enforcement of policies regarding resident possession of hazardous items, and prohibited items remained accessible over multiple days. The affected residents had varying degrees of cognitive and physical impairment, and facility policies requiring a safe environment and supervision were not consistently followed.
Two residents requiring dialysis did not receive care consistent with professional standards due to incomplete communication and documentation between the facility and the dialysis center. Hemodialysis Communication Records were frequently missing, incomplete, or unsigned, and there was no established process or policy for ensuring these records were properly managed or audited by facility staff.
Surveyors found that staff failed to properly store chemicals and personal beverages, left lettuce uncovered in the refrigerator, and did not consistently document freezer and food temperatures, including pureed and cold foods. The CDM and other staff acknowledged these lapses, which were contrary to facility policy and FDA Food Code requirements.
Multiple infection control lapses were observed, including a medication aide not sanitizing a blood pressure cuff between residents, an LVN failing to wear a PPE gown while administering medication via PEG tube to a resident on enhanced barrier precautions, and two CNAs not performing hand hygiene between glove changes during incontinent care for a resident with C. difficile and chronic kidney disease.
A resident with dementia and physical impairments did not consistently receive a prescribed lateral positioning device during meals, as outlined in the care plan. Staff were unclear about the resident's needs and responsibilities for providing the device, resulting in the resident being unable to sit upright and eat independently during observed meal service.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper incontinent care, as CNAs failed to perform hand hygiene between glove changes and after contact with soiled linen, and did not follow the correct order of care. Staff interviews revealed a lack of understanding of hand hygiene requirements, and facility policy confirmed these protocols were not followed.
A resident with diabetes and other complex conditions experienced multiple days of high blood glucose readings, but nursing staff did not document notifying the physician or receiving recommendations, despite facility policy requiring such documentation. Interviews confirmed that while staff claimed to have informed the physician, no evidence was found in the clinical record.
A resident with multiple medical conditions and intact cognition verbally complained about his labeled food being discarded after storing it in a refrigerator near the nurses' station. Staff confirmed the complaint was verbally reported to management, but no grievance form was completed and the incident was not documented in the grievance log, contrary to facility policy requiring written documentation and investigation of grievances.
A resident with cognitive impairment alleged that her ID card, social security card, and bank cards were stolen after a family visit, and that her social security check was moved to another account without her knowledge. The SW contacted APS and law enforcement, but the administrator did not report the incident to the state agency, believing it was unnecessary since only cards were involved and there was no confirmed theft of money. This action was inconsistent with facility policy, which requires reporting all allegations of misappropriation of resident property to the state agency.
A survey revealed that a LTC facility failed to provide adequate hydration to six residents, who did not have access to water or beverages in their rooms between meals. Residents with severe cognitive impairments were particularly affected, as they were unable to request water. Staff interviews confirmed that water was not routinely provided unless requested, and the facility's hydration policy was not consistently followed, leading to insufficient fluid offerings during meals.
A resident with severe cognitive impairment and physical limitations was transferred by a single CNA using a gait belt instead of the required two-person mechanical lift. The Hoyer lifts were unavailable due to dead batteries, and no alternative was sought. The transfer caused the resident discomfort, and the care plan was altered without consulting physical therapy. Staff acknowledged the need for a Hoyer lift, highlighting a significant oversight in ensuring resident safety.
A resident with dysphagia did not receive their prescribed mechanical soft diet with pureed meat texture during an evening meal service. Instead, they were served a grilled ham and cheese sandwich with whole ham, onion rings, and diced beets. The deficiency was confirmed by a CNA and an LVN, and the dietary manager later provided a corrected meal. The facility's process lacked proper verification of meal accuracy before distribution, and the DON indicated that nurses were responsible for checking meal trays, which was not done in this instance.
A resident with cerebral palsy and aphasia was physically abused by a CNA during a shower preparation, resulting in a head injury. The incident was witnessed by another CNA who delayed reporting due to fear. The facility's abuse policy was not effectively followed, leading to a failure in protecting the resident from harm.
A facility failed to accurately reflect a resident's status in the Quarterly MDS by not coding two falls without injury. The resident, on hospice with a history of falls, experienced unwitnessed falls that were not documented in the MDS. Interviews revealed that while the MDS Nurse believed coding did not impact care, the administrator noted that incorrect MDS assessments could affect care plans.
A resident was improperly discharged from an LTC facility after a delayed return from leave due to car issues. Despite notifying the facility, she was not allowed to re-enter, and her room was reassigned. The facility failed to provide a 30-day notice or appeal rights, violating her discharge rights.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed improperly sealed food containers, a dented can of pineapples, an expired bag of brownie mix, disinfectant wipes on the ice dispenser, and a dirty microwave. The Dietary Manager acknowledged these issues.
The facility failed to assist residents in voting during the March 5th election and did not have a plan for upcoming elections. Residents expressed concerns about not being assisted and alleged that grievances were being disposed of without review. The Social Worker and Activity Director were unaware of their responsibilities regarding election coordination, and the Administrator denied any wrongdoing.
The facility failed to address resident grievances regarding lost clothing after laundry service for at least six months. Despite multiple complaints from residents and their families, the facility did not take effective action to resolve the issue, leading to dissatisfaction and a diminished quality of life for the residents.
The facility failed to ensure residents received their mail on Saturdays and allegedly disposed of grievances without review. Despite residents' complaints and the hiring of a weekend receptionist, no one contacted the USPS to resume Saturday deliveries.
The facility failed to maintain hot water in resident bathrooms, resulting in temperatures significantly below the required 100 degrees F. Residents reported greasy hair, foul smells, and discomfort due to the inability to shower properly. Staff confirmed that bed baths were provided instead of showers, and some residents had not received a bed bath for several days. The issue persisted for at least a week, and the facility did not report the problem to the state.
The facility failed to report alleged violations involving abuse, neglect, and misappropriation of property within the required timeframes. Additionally, the facility did not report a lack of hot water for residents from March 26, 2024, to April 4, 2024, leading to residents receiving bed baths instead of showers. These failures could place residents at risk for mistreatment.
The facility failed to monitor a resident's cardiac pacemaker and address another resident's diarrhea. One resident did not have medical information needed to monitor his pacemaker, and staff were uncertain about parameter orders. Another resident experienced multiple instances of loose bowel movements without receiving a physician's order for treatment. The lack of documentation and communication among staff contributed to these deficiencies.
The facility failed to ensure a safe environment by not removing hazardous items such as scissors and disposable razors from resident rooms, despite the residents' cognitive and physical impairments, placing them at risk of harm or injury.
The facility failed to ensure proper communication and documentation for two residents requiring dialysis treatments, leading to incomplete and missing Dialysis Communications Records, which could affect the continuity of care and resident safety.
The facility had a medication error rate of 32%, involving a resident with multiple diagnoses. Eight medications were administered late due to lost keys to the medication cart. The DON confirmed that late administration is considered a medication error.
The facility failed to inform a resident of changes in Medicaid/Medicare coverage and potential liability for services not covered, resulting in an $8,502.60 bill. The resident, with moderate cognitive impairment, was stressed and worried about managing the bill and affording food. The Business Office Manager delayed notification, and the resident only received the bill on 04/01/2024.
A resident was found to have multiple medications stored in his room and admitted to self-administering them, contrary to facility policy. The ADON and DON confirmed that the resident was not permitted to self-administer medications, and all medications should be stored in locked compartments accessible only to authorized personnel.
A facility failed to maintain an infection prevention and control program for a resident on enhanced barrier precautions. An LVN did not initially wear a gown and failed to use appropriate hand hygiene during a medication pass, leading to potential cross-contamination.
Failure to Identify and Document Pressure Injury on Admission
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to identify and document a deep tissue injury (DTI) on a resident's left heel upon readmission from the hospital. The resident, an elderly female with a history of cerebral infarction, type 2 diabetes, congestive heart failure, and anemia, was assessed as having intact cognition but required substantial to maximum assistance with mobility and transfers. The resident was at risk for pressure ulcers, as indicated in her care plan and assessments prior to hospitalization, but no skin issues were documented at the time of her readmission assessment by the RN. Upon review, it was found that the hospital discharge documentation noted a left heel pressure ulcer with skin intact, but the RN's clinical admission assessment stated there were no skin issues. The Wound Treatment Nurse later identified a DTI on the left heel during a follow-up assessment and obtained physician orders for treatment. Interviews revealed that the RN did not recognize or document the DTI during the initial assessment, and she stated uncertainty about identifying certain skin concerns, such as redness, as wounds. The RN also indicated that she would wait for the Wound Treatment Nurse to assess and would not contact the physician for treatment orders immediately. The Director of Nursing (DON) confirmed that the admitting nurse is responsible for completing a thorough head-to-toe skin assessment and documenting any findings on the clinical admission assessment, as well as notifying the treatment nurse. The DON stated that any skin concerns, even if not fully staged, should be documented and monitored from the date of admission. The facility's policy requires accurate clinical documentation to communicate the patient's health status and care needs. The failure to identify and document the DTI on admission resulted in a deficiency related to ensuring nursing staff have the appropriate competencies and skills to provide safe and effective care.
Failure to Follow Enhanced Barrier Precautions During Direct Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow enhanced barrier precautions (EBP) while providing direct care to a resident with a Foley catheter. The resident, a male with diagnoses including Type 2 Diabetes, hemiplegia, and chronic kidney disease, was dependent on staff for toileting hygiene and had an indwelling Foley catheter. The resident's care plan, medication administration record, and physician orders all indicated the need for EBP, specifically the use of gown and gloves during high-contact care activities. During an observation, the CNA was seen exiting the resident's room after changing the resident's brief and emptying the Foley catheter bag, carrying a bag containing a used brief and gloves. The resident confirmed that the CNA wore gloves but did not wear a gown during the care. The resident also stated that staff typically did not wear gowns when providing care to him, despite the EBP signage on his door and the presence of gowns in his room. In interviews, the CNA acknowledged that she had recently received training on infection control and EBP, understood which residents required EBP, and knew that gowns and gloves were required for direct care of residents with Foley catheters or wounds. The Director of Nursing (DON) also confirmed that staff had been trained on EBP and that the expectation was for staff to wear gowns and gloves when providing direct care to residents on EBP. Facility policy and CMS guidance were reviewed, both of which supported the requirement for gown and glove use during high-contact care for residents with indwelling devices.
Failure to Ensure Timely and Private Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. During a confidential resident group meeting, all nine residents reported that they did not receive mail on Saturdays because the Business Office was not operational on weekends, despite the presence of a receptionist. Interviews with the Receptionist and Business Office Manager confirmed that while the Receptionist worked weekends and delivered packages, regular mail was left in the Business Office to be sorted and was not consistently distributed to residents on Saturdays. The Business Office Manager stated that mail delivered on Saturdays should be distributed the same day, but this was not consistently happening, resulting in residents not receiving their mail in a timely manner.
Failure to Prevent Accident Hazards Due to Unsafe Items in Resident Rooms
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards for three residents, as evidenced by the presence of potentially dangerous items in their rooms. One resident, with a history of dementia, lack of coordination, and chronic pain, was repeatedly observed with a large pair of nail clippers and tweezers on her bedside table. Staff interviews revealed inconsistent understanding and enforcement of facility policy regarding residents' possession of such items, with some staff stating that no residents were allowed to cut their own nails or possess nail clippers or tweezers, while others referenced the resident's cognitive status as a factor in allowing possession. The facility's care plan for this resident indicated a need for supervision with personal hygiene, but the items remained accessible over multiple days. Another resident, with moderate cognitive impairment, muscle weakness, and a history of falls, was found with a pair of sharp scissors and a disposable razor on her bedside table. The resident stated she used the scissors for eating candy and could use the razor with one hand. Staff confirmed that the resident did not shave herself and that such items should not be left at the bedside, indicating a lapse in supervision and room checks. The items were believed to have been brought in by family, but staff were unclear on their origin and only removed them after being alerted. A third resident, with mild cognitive impairment and a history of altered mental status, was found with an all-purpose cleaner in her restroom. The cleaner was not facility-issued, and housekeeping staff stated it was not their product. Nursing staff and the DON confirmed that chemicals were not allowed in resident rooms, and that all staff were responsible for removing prohibited items. The presence of the cleaner was attributed to possible family involvement, but it remained in the resident's room until discovered during the survey. Facility policy review indicated a requirement for a safe environment and proper handling of personal hygiene equipment, but these were not consistently followed.
Failure to Maintain Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure proper communication, coordination, and collaboration with the dialysis center for two residents who required dialysis services. For one resident with end stage renal disease and a history of traumatic amputation and anemia, multiple Hemodialysis Communication Records were either incomplete, missing, or not signed by facility nurses or dialysis staff. The resident's care plan required monitoring of the dialysis site and communication with the dialysis center, but records showed repeated lapses in documentation and follow-up. Interviews with staff revealed confusion about the process for handling communication records, with some staff admitting to filing incomplete forms and not notifying supervisors when information was missing. Another resident, admitted with severe sepsis, acute kidney failure, and dependence on dialysis, also had deficiencies in the completion of Hemodialysis Communication Records. Several records lacked signatures from either the dialysis facility nurse or the facility nurse, and there was a consistent absence of required identifying information such as the resident's name, ID number, and physician's name. The DON confirmed that the forms were not fully completed because they were stored in a binder labeled with the resident's name and then uploaded into the electronic medical record, rather than being filled out in full as required. Interviews with facility leadership, including the DON and regional nurse, revealed that there was no established policy or process for tracking or auditing the Hemodialysis Communication Records. The DON acknowledged that nobody was consistently auditing the records to ensure completeness, and there was no system in place to ensure that all necessary information was obtained from the dialysis center before filing the records. This lack of process contributed to the ongoing deficiencies in communication and documentation for residents receiving dialysis.
Deficiencies in Food Storage, Preparation, and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to the storage, preparation, distribution, and serving of food. During an initial kitchen tour, a cleaning spray was observed stored on the bottom shelf of a refrigerator and placed near food during meal preparation. The Certified Dietary Manager (CDM) acknowledged that chemicals should not be stored in the refrigerator or near food, as staff had been trained to prevent cross-contamination. Facility policy also required chemicals to be stored in a separate and secured area. Further review of records revealed that freezer temperature logs were incomplete, with missing entries for several days. The CDM was unable to explain the omissions but confirmed oversight of the temperature log. Facility policy required monitoring of frozen food storage temperatures to ensure food safety. Additionally, personal beverages were found stored above the food preparation area while staff were prepping food, which the CDM confirmed was not permitted due to the risk of cross-contamination. The U.S. FDA Food Code was cited, emphasizing the need to protect food from contamination by proper storage. Other deficiencies included uncovered lettuce stored in the walk-in refrigerator, which the CDM initially justified due to a lack of appropriately sized containers. Facility policy required all food items to be stored in covered containers to prevent cross-contamination. The facility also failed to document temperatures for pureed foods and cold foods over several days, and no food temperatures were recorded for one dinner service. The CDM stated that temperatures were not taken for pureed foods or cold milk, believing it unnecessary if regular foods were at proper temperatures. Interviews with the Registered Dietitian (RD) and Director of Nursing (DON) confirmed the importance of proper chemical storage, food storage, and temperature monitoring for food safety, as outlined in facility policies and the FDA Food Code.
Infection Control Lapses During Resident Care and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. During a medication pass, a medication aide did not sanitize a blood pressure cuff between use on two different residents. The aide acknowledged forgetting to sanitize the cuff, which is necessary to prevent cross contamination between residents. In another instance, a licensed vocational nurse administered medication via a PEG tube to a resident who was on enhanced barrier precautions due to the presence of a feeding tube and a urinary catheter. The nurse wore gloves but did not don a PPE gown as required by the resident's care plan and physician orders for enhanced barrier precautions. Facility policy and CMS guidance require the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. Additionally, two certified nursing assistants provided incontinent care to a resident with a history of dementia, enterocolitis due to C. difficile, and chronic kidney disease. The CNAs did not perform hand hygiene between glove changes during the care process, despite removing and replacing gloves multiple times. Both CNAs stated they were not trained to sanitize their hands between glove changes, although facility policy and the nursing supervisor indicated that hand hygiene should be performed at these times.
Failure to Implement Comprehensive Care Plan for Positioning Device During Meals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, malnutrition, and lack of coordination. The resident's care plan indicated the use of a lateral supporting positioning device (cushion) to assist with upright posture during meals, but this intervention was not consistently implemented. During a lunch meal observation, the resident was found leaning to one side in his wheelchair and unable to eat, with no cushion in place. Staff interviews revealed a lack of awareness and communication regarding the resident's need for the cushion, with some staff unsure of the care plan details and others relying on therapy staff for guidance. Further observations confirmed that the cushion was not always provided as required by the care plan, and staff interviews indicated inconsistent understanding of who was responsible for ensuring the intervention was in place. The facility's own policy required comprehensive care plans with measurable objectives and timeframes, but the care plan for this resident was not fully implemented, resulting in the resident not receiving necessary support to maintain an upright posture during meals.
Failure to Follow Proper Incontinent Care and Hand Hygiene Protocols
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate incontinent care to a female resident with severe cognitive impairment, chronic kidney disease, and a history of clostridium difficile infection and bacteremia. During observed care, the CNAs did not follow proper hand hygiene protocols, as they repeatedly changed gloves without sanitizing their hands in between glove changes. One CNA also failed to change gloves or perform hand hygiene after touching soiled linen. Additionally, the care was not performed in the correct order, as barrier cream was applied to the buttocks before the vaginal area, contrary to facility policy and infection prevention standards. Interviews with the CNAs revealed a lack of understanding regarding the need for hand hygiene between glove changes, despite recent training. The nursing supervisor and DON confirmed that staff are expected to sanitize hands between glove changes and after contact with soiled items. Review of the facility's policy corroborated these requirements, specifying hand washing after removing soiled gloves and before donning new ones. Requested documentation of the CNAs' competencies or training was not provided prior to the survey exit.
Failure to Document Physician Notification for High Blood Glucose Levels
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with multiple complex diagnoses, including type 2 diabetes with ketoacidosis, sepsis, and metabolic encephalopathy. Over a period of five days, the resident experienced consistently high blood glucose levels, with readings above 200 mg/dL and reaching as high as 337 mg/dL. Despite these abnormal results, there was no documentation by the nursing staff (RN B and LVN C) indicating that the physician was notified or that any recommendations from the physician were received or implemented. The resident was not prescribed insulin and was only receiving oral antidiabetic medication. Review of the resident's care plan and physician orders confirmed that staff were expected to monitor for abnormal blood glucose levels, report them to the physician, and document any interventions or physician communications. However, nursing progress notes contained no entries regarding the high blood glucose levels during the period in question. Interviews with nursing staff and the DON revealed that while staff claimed to have notified the physician, this was not documented in the medical record. The DON acknowledged that best practice would be to write a note, and the facility's policy required documentation of physician notifications and orders. The lack of documentation regarding physician notification and response for the resident's elevated blood glucose levels was confirmed through record review and staff interviews. The physician stated he was always notified of high blood glucose readings, but there was no evidence of this in the clinical record. The facility's policy on following physician orders required that all such communications and interventions be documented, which was not done in this case.
Failure to Document and Investigate Resident Grievance Regarding Discarded Food
Penalty
Summary
The facility failed to ensure that all written grievance decisions included required documentation such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings or conclusions, confirmation status, corrective actions, and the date the decision was issued. Specifically, a resident with diagnoses including cerebrovascular disease, dysphagia, aphasia, depression, and generalized anxiety disorder, who was cognitively intact, verbally complained about his food being discarded after storing it in a refrigerator near the nurses' station. The resident reported labeling his food with his name and date, but discovered it was missing when he attempted to retrieve it. Interviews with facility staff, including the social worker, LVN, DON, and administrator, confirmed that the resident had a history of storing his own food and had previously raised concerns about food being discarded. The LVN recalled the resident being upset about his food being thrown away and stated she verbally reported the grievance to the ADON (now DON). However, there was no documentation of this grievance in the facility's grievance log, and no grievance form was completed for the incident. The facility's grievance policy requires that all concerns be documented and investigated, with a written decision provided. Despite this, the process was not followed in this case, as the resident's complaint was not formally documented or investigated according to policy. The lack of documentation and follow-through could prevent residents' concerns from being properly addressed and resolved.
Failure to Report Alleged Exploitation and Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving exploitation and misappropriation of resident property were reported to the state agency as required. Specifically, a female resident with moderately impaired cognition and a history of cerebral atherosclerosis and morbid obesity reported that her ID card, social security card, and bank cards were missing from her wallet after a family visit. She also alleged that her monthly social security check was moved to another account without her knowledge. The social worker (SW) documented these allegations and took steps to contact Adult Protective Services (APS) and the police, and the administrator signed off on the grievance report. Despite these actions, the facility did not report the allegations to the state agency. The SW stated she was unaware that such allegations needed to be reported to the state agency and believed that notifying the administrator was sufficient, as the administrator typically handled reporting. The administrator confirmed awareness of the allegations and that reports were made to APS and the police, but did not report to the state agency, believing it was unnecessary since only cards were involved and there was no confirmed theft of money. The administrator also admitted unfamiliarity with the facility's reporting policy and indicated a need to review it for requirements. Facility policy requires reporting all allegations of misappropriation of resident property, exploitation, and mistreatment to the administrator, state agency, APS, and other required agencies within specified timeframes. The policy specifically includes misappropriation of resident property as a reportable incident, regardless of whether serious bodily injury occurred. The failure to report the incident to the state agency was contrary to both facility policy and regulatory requirements.
Inadequate Hydration Practices in LTC Facility
Penalty
Summary
The facility failed to provide adequate hydration to six residents, as observed during a survey. Residents did not have access to water or beverages in their rooms between meals, and the facility did not ensure that 16 ounces of fluid were offered with meals. This deficiency was noted for residents with severe cognitive impairments, such as Alzheimer's disease, dementia, and intellectual disabilities, who were unable to advocate for themselves or request water due to their conditions. Observations revealed that residents' rooms lacked water pitchers or beverages, and staff interviews confirmed that water was not routinely provided unless requested by the residents. For instance, one resident with severe cognitive impairment was observed without water in her room, and staff stated that she did not ask for water. Another resident, who required nectar-thick fluids, was only provided with small amounts of thickened tea and water during meals, and no additional fluids were available in her room. The facility's hydration policy was not consistently followed, as evidenced by the lack of water pitchers in residents' rooms and the insufficient fluid offerings during meals. Interviews with staff, including CNAs and the Dietary Manager, highlighted inconsistencies in the provision of fluids, with some staff unaware of the facility's hydration policy. The Registered Dietitian and Director of Nursing acknowledged the importance of hydration but noted that the responsibility for ensuring adequate fluid intake rested with the nursing staff, who were not consistently providing fluids as required.
Failure to Provide Adequate Transfer Assistance
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who was dependent on staff for transfers due to severe cognitive impairment and physical limitations. The resident's care plan required a two-person mechanical lift transfer, but on the day of the survey, the transfer was conducted by a single CNA using a gait belt instead of the required Hoyer lift. This deviation from the care plan occurred because the Hoyer lifts were not operational due to dead batteries, and no alternative lift was sought from other parts of the building. During the transfer, Resident #1 was lifted by a single CNA in a bear-hug position, which was not in accordance with the care plan. The resident expressed discomfort during the transfer, making grunting noises and saying "ouch." Despite the presence of a second CNA, the transfer was not conducted as a two-person operation, and the resident was not provided with the necessary mechanical assistance. The failure to follow the care plan and provide adequate supervision and assistance devices placed the resident at risk for injury. Interviews with staff revealed that the decision to alter the care plan was made by the Administrator without consulting the physical therapy department. The Administrator changed the care plan to a two-person transfer without mechanical assistance due to the unavailability of the Hoyer lift. However, the transfer was still conducted by only one staff member, contrary to the revised care plan. The Director of Nursing and other staff acknowledged that the resident required a Hoyer lift for safe transfers, and the failure to adhere to the care plan was a significant oversight.
Failure to Provide Prescribed Diet to Resident
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident who required a mechanical soft diet with pureed meat texture due to dysphagia. On the evening meal service, the resident received a meal tray containing a grilled ham and cheese sandwich with whole ham, onion rings, and diced beets, which did not meet the prescribed diet. The resident's care plan and physician orders specified a diet of mechanical soft with pureed meat, but this was not followed during the meal service. The deficiency was observed when a CNA and an LVN confirmed that the meal did not contain pureed meat as required. The dietary manager later provided a corrected meal tray with pureed items. The facility's dietary process involved dietary aides and a cook preparing meals, but there was a lack of verification of meal accuracy before trays were distributed. The DON stated that nurses were responsible for checking meal trays for accuracy before they were given to CNAs to pass out, but this procedure was not followed, leading to the resident not receiving the diet as ordered by the physician.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) who hit a resident on the head. The resident, who has cerebral palsy, aphasia, and requires extensive assistance with daily activities, was being prepared for a shower by two CNAs. During this process, the resident became agitated and began hitting out, at which point one of the CNAs struck the resident on the forehead, resulting in a visible knot. The incident was witnessed by the second CNA, who initially did not report it due to fear of the offending CNA. The witness CNA eventually reported the incident to a Medication Aide, who then informed a Licensed Vocational Nurse (LVN). The LVN confirmed the presence of a knot on the resident's head, which was not present after a previous fall, indicating the injury was a result of the CNA's actions. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of such incidents. However, the initial failure to report and intervene in the abusive situation allowed the incident to occur and placed the resident at risk of harm. The facility's documentation and interviews with staff revealed that the abuse policy was not effectively followed at the time of the incident.
Failure to Accurately Reflect Resident's Status in MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident reviewed for accuracy of assessments. Specifically, the facility did not code the resident's Quarterly MDS for two falls without injury that occurred on specific dates. The resident, who was on hospice services and had a history of falling, experienced unwitnessed falls on two occasions. Despite being assessed and found to have no apparent injuries after each fall, these incidents were not documented in the Quarterly MDS as required. Interviews with the MDS Nurse and the facility administrator revealed that the MDS assessments are crucial for triggering care needs and starting a care plan. The MDS Nurse acknowledged the oversight but stated that MDS assessment coding did not impact patient care because facility nurses do not look at the MDS assessments. However, the administrator emphasized that incorrect MDS assessments could affect the amount of care a resident receives, as they impact the care plan. The facility's policy on MDS Completion requires accurate representation of the resident's clinical status, which was not adhered to in this case.
Improper Discharge of Resident Without Notice or Appeal Rights
Penalty
Summary
The facility failed to ensure proper procedures were followed for the discharge of a resident, leading to a deficiency in the resident's rights. A resident was discharged after not returning from a leave within 72 hours, despite notifying the facility of car issues that delayed her return. Upon her return, she was informed that she had been discharged, her belongings were packed, and she was not allowed to re-enter the facility or given the option to pay privately. The resident was not provided with a documented discharge or the right to appeal the discharge, which is a violation of her rights. The resident had a complex medical history, including diagnoses of chronic pain, dementia, and major depressive disorder, among others. She was dually certified for Medicare and Medicaid services and required assistance with daily activities due to her medical conditions. The facility's actions did not align with the resident's care plan, which indicated she was in the facility for long-term care placement and did not require discharge planning. Interviews with facility staff revealed that the resident's room was reassigned to another resident, and there were available beds in the facility. However, the facility did not issue a 30-day notice or provide the necessary documentation for the resident to appeal the discharge. The facility's failure to follow proper discharge procedures and communicate effectively with the resident and her representatives resulted in a deficiency that could affect all residents by denying them the opportunity to appeal a discharge.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed two plastic storage containers in the dry storage room that were not properly sealed, exposing the contents to potential contamination. Additionally, a dented can of pineapples and an expired bag of brownie mix were found in the dry storage room. A container of disinfectant wipes was also observed on top of the ice dispenser, and the microwave was dirty with old food particles inside. During an interview, the Dietary Manager acknowledged the issues, confirming that the microwave was dirty, the can of pineapples was dented, the disinfectant wipes were improperly placed on the ice machine, and the lids on the storage containers were not tightly sealed. The facility's policy and the U.S. FDA Food Code were reviewed, both of which emphasize the importance of protecting food from contamination by storing it in clean, dry locations where it is not exposed to splash, dust, or other contaminants.
Failure to Assist Residents in Voting
Penalty
Summary
The facility failed to treat each resident with respect and dignity and care in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, the facility did not offer residents the opportunity to vote in the March 5th election and did not have a plan in place for the upcoming elections on May 28th and November 5th. This failure was identified during a group interview where five residents expressed their concerns about not being assisted in voting, despite having made verbal and written complaints to the Social Worker and Administrator. The residents also alleged that paper grievances were being disposed of by administrative staff without being reviewed. The Social Worker, who had been at the facility since February 2022, stated that she was not responsible for coordinating resident voting and had not received any grievances related to voting. The former Activity Director, who left the facility in March 2024, confirmed that coordinating elections was part of her role but was unable to fully brief her replacement due to a short transition period. The current Activity Director, who started on March 13, 2024, was not informed about the responsibility of coordinating elections and had no plans to do so until the issue was brought to her attention during the investigation. The Administrator was unaware of the residents not being assisted in voting for the March 5th election and believed that the responsibility lay with the Activity Director. The Administrator denied any allegations of grievances being disposed of without review and stated that all paper grievances were followed up for resolution. A review of resident council grievances from October 2023 to March 2024 showed no recorded concerns about voting coordination. The facility's policy on Resident Rights emphasized the residents' right to exercise their rights as citizens, including the right to vote, without interference or discrimination.
Failure to Address Resident Grievances on Lost Clothing
Penalty
Summary
The facility failed to consider the views of a resident or family group and act promptly upon grievances and recommendations concerning issues of resident care and life in the facility. Specifically, the facility did not return residents' clothes after laundry service for at least six months, despite receiving individual and resident council grievances. This issue was documented in resident council minutes from October 2023 to March 2024, and individual grievances were also recorded, indicating a persistent problem with lost clothing items. Residents and their family members reported missing clothes, and the facility's responses were inadequate or delayed, leading to unresolved grievances and dissatisfaction among residents and their families. Interviews with residents, family members, and staff revealed a lack of effective communication and follow-up on the grievances. Residents reported that their concerns about missing clothes were verbally and in writing communicated to the Social Worker and Administrator, but they did not receive satisfactory resolutions. Additionally, residents alleged that the Administrator disposed of paper grievances without reviewing them. The Social Worker and EVS Manager acknowledged receiving grievances related to lost clothes but did not identify a systemic issue or take effective action to resolve the problem. The EVS Manager identified that the primary reason for the lost clothes was insufficient identification on the clothing items, which was supposed to be done by the nursing staff. However, the Administrator denied that staff were not supporting dependent residents in marking their clothes. The facility's policy on resident rights emphasized the right to retain and use personal possessions, including clothing, but the facility failed to uphold this right, leading to a diminished quality of life for the residents involved.
Failure to Ensure Timely Mail Delivery and Proper Grievance Handling
Penalty
Summary
The facility failed to ensure that residents had reasonable access to their mail, particularly on Saturdays. Four residents reported that they had not received their mail on Saturdays for several months and had raised concerns with the Social Worker and Administrator without receiving a resolution. The residents also alleged that their grievances were being disposed of without review. The Business Office Manager (BOM) confirmed that the USPS had stopped delivering mail on Saturdays due to the absence of a weekend receptionist, and no one had contacted the local post office to resume Saturday deliveries even after a weekend receptionist was hired. The Activity Director and Administrator were also aware of the issue but had not taken steps to resolve it. The facility's policy on resident rights states that residents have the right to send and receive mail and to have privacy in their communications. Despite this policy, the facility did not ensure that residents received their mail on Saturdays, and there were allegations of grievances being improperly handled. The Administrator denied any risk associated with the delay in mail delivery and the improper handling of grievances, but the residents' complaints and the BOM's statements indicate a failure to address the issue adequately.
Failure to Maintain Hot Water in Resident Bathrooms
Penalty
Summary
The facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment by not maintaining hot water at a comfortable temperature in resident bathrooms. Observations revealed that the bathroom sinks in multiple resident rooms had water temperatures significantly below the required 100 degrees F, with temperatures ranging from 70.0 to 72.0 degrees F. Interviews with residents indicated that the lack of hot water had persisted for at least a week, with some residents reporting greasy hair and foul smells due to the inability to shower properly. Residents expressed frustration and discomfort, with some being unaware of alternative showering options available on the other side of the building where hot water was still functioning. Staff confirmed that bed baths were being provided instead of showers due to the hot water issue, and some residents had not received a bed bath for several days. The Maintenance Director and Administrator acknowledged the problem, stating that both hot water heaters on the south side of the building had failed, and they were waiting for replacements. The Administrator mentioned that residents were informed about the option to shower in rooms with hot water on the north side of the building, but some residents were either not informed or chose not to use this option. The facility's policy on resident rights emphasizes the importance of a safe, clean, and comfortable environment, which was not upheld in this instance. Record reviews showed that the hot water issue had been documented, but the facility did not report the problem to the state, believing it was not necessary. The lack of hot water and the facility's response to the issue resulted in a diminished quality of life for the affected residents.
Failure to Report Alleged Violations and Lack of Hot Water
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframes. Specifically, the Administrator did not report to the state agency an incident involving Resident #17's missing rings in December 2023. Despite an internal investigation, there was no documentation or report made to the state. Interviews with the LVN ADON, DON, and Administrator confirmed that the incident was known but not reported as required by regulations. Additionally, the facility did not report to the state agency that residents did not have access to hot water for an indeterminate amount of time from at least March 26, 2024, to April 4, 2024. Multiple residents and staff confirmed the lack of hot water, which led to residents receiving bed baths instead of showers. The Maintenance Director and Administrator were aware of the issue, but the Administrator did not believe it was necessary to report it to the state. Interviews with residents revealed dissatisfaction and discomfort due to the lack of hot water and the alternative bathing arrangements. The failure to report these incidents in a timely manner could place residents at risk for abuse, neglect, exploitation, and mistreatment. The facility's policies and procedures for reporting and documenting such incidents were not followed, leading to a lack of accountability and oversight in addressing these serious issues.
Failure to Monitor Cardiac Pacemaker and Address Diarrhea
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice for two residents. Resident #65, a male with severe cognitive impairment and a cardiac pacemaker, did not have medical information needed to monitor the parameters of his pacemaker. The resident's care plan included monitoring for signs of pacemaker malfunction, but there were no orders or documentation identifying normal pacemaker pulse limits. Interviews with staff revealed that the pacemaker was checked every six months by an external cardiologist, and there was uncertainty about whether the family had refused parameter orders. The Director of Nursing (DON) was unaware of the specific monitoring requirements and stated that nursing judgment was used for changes in condition, but no specific policy for cardiac pacemakers was provided by the Administrator when requested. Resident #47, a male with major depressive disorder, experienced twenty-three instances of loose bowel movements over thirty days without receiving a physician's order for treatment. The resident reported the issue to a nurse but did not receive any changes to address the diarrhea. Interviews with staff indicated that the aides did not inform the charge nurse about the resident's condition, and the DON was unaware of the issue. The facility's policy required aides to report changes in bowel movements to the charge nurse, who would then contact the physician for appropriate orders. The DON acknowledged that prolonged diarrhea could lead to dehydration and emphasized the importance of communication between aides and nurses. The facility's failure to obtain necessary medical information and physician orders for these residents could place them at risk for not having care and services provided to meet their needs. The lack of documentation and communication among staff members contributed to the deficiencies in care for both residents.
Failure to Remove Hazardous Items from Resident Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for four residents. Resident #51, who was moderately cognitively impaired and had impaired visual function, was observed with a large pair of scissors on his bedside table on multiple occasions. Despite the resident's cognitive and visual impairments, the facility did not have a rule against the resident having scissors unless there was a specific reason, and the Assistant Director of Nursing (ADON) stated that Resident #51 was capable of using the scissors without further elaboration. Additionally, the facility failed to ensure that disposable razors were not left on the bathroom counters of three other residents. Resident #33, who had dementia and impaired vision, was observed with two disposable razors on his bathroom counter. Resident #70, who had moderate cognitive impairment and required supervision for personal hygiene, was observed with two disposable razors on his bathroom counter. Resident #71, who had moderate cognitive impairment and required extensive assistance for personal hygiene, was observed with three disposable razors on his bathroom counter. The Director of Nursing (DON) and the Administrator acknowledged that residents were allowed to shave on their own but stated that staff were expected to supervise residents for safety and ensure razors were discarded in sharps containers. The facility's failure to remove scissors and disposable razors from residents' rooms and bathrooms, despite the residents' cognitive and physical impairments, placed the residents at risk of harm or injury. The facility did not provide a policy for shaving and resident hygiene when requested, indicating a lack of clear guidelines to prevent such hazards.
Failure to Maintain Proper Dialysis Communication Records
Penalty
Summary
The facility failed to ensure proper communication, coordination, and collaboration with the dialysis facility for two residents requiring dialysis treatments. For Resident #51, the facility did not maintain complete and accurate Dialysis Communications Records. Multiple records were found to be incomplete or missing, including pre and post-treatment evaluations, vital signs, and signatures from both facility and dialysis staff. Despite the resident not reporting any issues with dialysis treatments, the lack of proper documentation and communication could lead to potential complications being overlooked. Resident #82 also experienced similar issues with incomplete dialysis communication. The resident's dialysis binder was lost during a hospital visit and was never recovered. The facility had ongoing issues with retrieving dialysis binders from the dialysis center, and the nursing staff failed to ensure the Dialysis Communications Records were completed. The Assistant Director of Nursing (ADON) acknowledged the problem but did not have a consistent process to address it. The Director of Nursing (DON) and the Administrator also recognized the need for a better process to ensure complete and accurate communication records. The facility's policy on Hemodialysis Communication Forms was not followed, leading to gaps in documentation and communication between the facility and the dialysis center. This failure in maintaining proper records and communication could result in a break in the continuity of care for residents receiving dialysis treatments, potentially affecting their health and safety.
Medication Error Rate Exceeds Acceptable Limits
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5% or greater, with an observed error rate of 32%. This involved one resident, a female with multiple diagnoses including cerebrovascular disease, diabetes, and hypertension, among others. The resident's medication administration was reviewed, and it was found that eight medications were administered late by a Medication Aide (MA D) due to the keys to the medication cart being lost. The medications were scheduled for 8:00 a.m. and 9:00 a.m. but were administered between 10:31 a.m. and 10:39 a.m. on the day of the observation. During an interview, MA D revealed that the delay was due to the lost keys and that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) instructed her to administer the medications late, with the assumption that the times would be adjusted and the doctor would be informed. The DON confirmed that medications given late are considered a medication error. The facility did not provide a policy and procedure for medication errors when requested by the Administrator.
Failure to Inform Resident of Medicaid/Medicare Coverage Changes
Penalty
Summary
The facility failed to inform Resident #70 of changes in Medicaid/Medicare coverage and potential liability for services not covered. The resident's liability changed from $0 to $1,395.90 for the period from 11/01/2023 to 12/31/2023, $1,427.70 for 01/01/2024 to 02/29/2024, and to $1,262.80 from 03/01/2024 ongoing. The facility did not notify the resident in a timely manner about these changes, resulting in an $8,502.60 bill on 04/01/2024. The resident, who had a moderate cognitive impairment, was stressed and worried about how he would manage to pay the bill and afford food, as he refused to eat the facility's food and relied on his monthly income for meals. The Business Office Manager (BOM) admitted to not notifying the resident of the letter received from Texas Health and Human Services in February because it was not considered official until it updated in the facility's program in mid-March. The BOM did not have a copy of the bill and notification provided to the resident in March, and the manual bill created was not saved. The BOM provided another original letter from Texas Health and Human Services dated 03/20/2024, which was addressed to the resident and the BOM. However, the resident stated he never received any mail from Texas Health and Human Services since the summer of 2023 and only received the bill on 04/01/2024. The facility's policy requires prompt and timely billing of all charges and notification to residents of any changes in their financial responsibilities. The Administrator confirmed that Medicaid notices should not be addressed to the BOM and that residents should receive their mail to stay informed. The failure to notify Resident #70 in a timely manner about the changes in liability and the subsequent large bill caused significant stress and confusion for the resident.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, Resident #51 had multiple medications, including eye drops, over-the-counter allergy gel capsules, anti-fungal cream, hydrocortisone cream, and Sevelamer Carbonate tablets, stored in his room. Resident #51 stated that he self-administered these medications and that only a few nurses were aware of this practice. The resident admitted to applying too much of the eye drops himself. During interviews, the ADON and DON confirmed that Resident #51 was not allowed to self-administer medications and that all medications should be administered by nursing staff. The facility's policy stated that all medications should be stored in locked compartments and only accessible to authorized personnel. The failure to adhere to these policies could result in adverse effects due to improper medication administration.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #62, who was on enhanced barrier precautions. During a medication pass, LVN E did not initially wear a gown and failed to use appropriate hand hygiene. LVN E left the bedside to obtain a tool to unclog the feeding tube, returned to the medication cart, and put on a gown and gloves without sanitizing her hands. LVN E then applied eye drops to the resident while continuing to use the same gloves, removed her gloves, sanitized her hands, and put on a new pair of gloves. LVN E placed her right hand into her scrub pocket to retrieve a pulse oximeter, used it on the resident, and placed it back into her pocket without changing gloves or sanitizing her hands before continuing with medication administration. Interviews with LVN E and the DON confirmed the failure to follow proper infection control protocols. LVN E acknowledged not wearing a gown and not using appropriate hand hygiene, which she recognized as an infection control issue. The DON emphasized the importance of wearing a gown for residents on enhanced barrier precautions to prevent infection and stated that hand hygiene should be performed before and after glove changes to avoid cross-contamination. The facility's policy on infection prevention and control requires all staff to assume that all residents could be potentially infected and to follow established hand hygiene procedures.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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