Alfredo Gonzalez Texas State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcallen, Texas.
- Location
- 301 E Yuma Ave, Mcallen, Texas 78503
- CMS Provider Number
- 676063
- Inspections on file
- 27
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Alfredo Gonzalez Texas State Veterans Home during CMS and state inspections, most recent first.
Two male residents with dementia‑related diagnoses and behavioral histories were involved in a resident‑to‑resident altercation in which one resident, described by staff as verbally aggressive, was reported by a CNA to have punched his roommate in the face and chest at the room doorway. An LPN assessed the roommate, documented no injuries, and the resident denied being hit; the DON and Administrator were notified but did not initiate an abuse investigation, did not separate the residents, and relied on intermittent monitoring instead of a room change or 1:1 supervision. Hours later, a second incident occurred in the same room, with staff finding the roommate on the floor with multiple skin tears and redness to the nose and the other resident nearby holding a bedside table and reportedly stating he would hit the roommate again. Nursing documentation reflected that the injured resident reported being pulled or pushed to the floor by the other resident. Surveyors determined the facility failed to protect the resident from abuse and to implement adequate protective interventions after the first reported altercation, resulting in Immediate Jeopardy past noncompliance.
Two cognitively impaired male residents with known behavioral histories were involved in a resident-to-resident altercation in which one resident was reportedly punched in the face and chest by his roommate, as witnessed and reported by a CNA. An LPN assessed the alleged victim, documented no injuries, and recorded that he denied being hit, and leadership decided not to initiate an abuse investigation or separate the residents, instead relying on limited and inconsistently documented monitoring. The residents continued to share a room, and a second incident occurred in which the same resident was found on the floor with bilateral arm and knee skin tears and facial redness, after he stated his roommate had pulled him down, while another CNA reported seeing the aggressor standing over him with a bedside table and threatening to hit him again, demonstrating a failure to implement abuse-prevention policies and adequate protective measures.
A resident with multiple comorbidities, moderate cognitive impairment, and identified risk for skin impairment did not receive weekly skin assessments as required by her care plan, physician orders, and the facility’s skin and wound policy. An existing order for weekly skin checks was discontinued and not renewed for several months, and no weekly skin and wound evaluations were documented during that time. The DON confirmed that nursing staff had not been performing or documenting weekly skin assessments for this resident despite the facility policy requiring licensed nurses to complete and record weekly skin checks.
A resident with severe dementia, anxiety, major depressive disorder without psychotic features, and insomnia received Seroquel 200 mg at bedtime as an antipsychotic without an adequate documented indication. The MDS showed severe cognitive impairment but no psychosis, while the care plan and consent listed multiple psychiatric diagnoses, and orders tied Seroquel to dementia with agitation and anxiety. The MAR confirmed administration over several days, and antipsychotic side effect monitoring was ordered. In interviews, the DON acknowledged that antipsychotics like Seroquel are not indicated for dementia and could not explain the associated risks, while a PA emphasized cautious use in the elderly. The facility’s psychotropic medication policy required appropriate use and monitoring, but surveyors determined that the indication for Seroquel use did not meet these standards.
Two residents with dementia-related and behavioral diagnoses were involved in a resident-to-resident altercation during which one resident was found on the floor with multiple skin tears and reported that his roommate had caused the fall. Nursing staff documented the injuries, completed assessments, and transferred the injured resident to the hospital, where no fractures were found. The abuse coordinator/administrator was notified of the alleged abuse and injuries but did not report the allegation to the state agency within the required 2-hour timeframe, despite facility policy and state guidance requiring immediate reporting of alleged abuse or events resulting in serious bodily injury.
Staff failed to consistently wear required PPE, including gowns and gloves, before entering the room of a resident on Enhanced Barrier Precautions. Despite clear signage, available supplies, and staff awareness of infection control protocols, both an LVN and a CNA provided care without donning appropriate PPE, resulting in a breach of the facility's infection prevention policy for a resident with complex medical needs.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to Enhanced Barrier Precautions (EBP) while caring for a resident with a PEG tube. Despite training and available PPE, the LVN entered the resident's room without donning a gown and gloves during high-contact activities, as confirmed by video footage and staff interviews. The resident, with severe cognitive impairment and requiring a feeding tube, was at risk due to this non-compliance.
The facility failed to maintain a sanitary environment in a resident's shower, as a dirty towel with brown colorations was found in the shower area on two separate occasions. Housekeeping staff claimed rooms were cleaned daily, but the towel remained, indicating a lapse in cleaning or communication. The DON and ADM were unaware of the issue until it was reported, acknowledging the importance of a clean environment.
A facility failed to maintain accurate medical records by continuing to log temperatures for a resident's personal refrigerator after it was taken home. Despite the refrigerator's removal, staff documented temperatures on the MAR, indicating a lapse in accurate record-keeping. Interviews with staff revealed a lack of awareness and policy guidance on maintaining accurate documentation.
Two LVNs at a facility failed to adhere to enhanced barrier precautions (EBP) by not wearing gowns while providing care to residents with PEG tubes and midline catheters. Despite available PPE and signage, the LVNs only wore gloves, citing reasons such as lack of recent training and forgetfulness. This non-compliance with the facility's infection control policy potentially risked cross-contamination and infection among residents.
Two residents with feeding tubes were admitted to a facility without physician orders for enhanced barrier precautions (EBP), despite the presence of PPE and signage indicating the need for such measures. The ADON and DON confirmed the oversight, attributing it to a lack of formal training and adherence to policy, potentially placing residents at risk of infection.
A facility failed to follow its policy on the storage of foods brought by family for a resident with a personal refrigerator. The resident, with Parkinson's disease and other conditions, had a care plan requiring daily temperature logs for the refrigerator, which were incomplete for October. The DON admitted the policy was not followed, and the resident's family stated the fridge was for the resident's pleasure feeding items, contrary to the DON's claim. This oversight could risk foodborne illness.
A resident with severe cognitive impairment and diagnoses of congestive heart failure and pleural effusion was not provided oxygen at the prescribed rate, as observed during a survey. The resident was found receiving oxygen at 3 Lpm instead of the prescribed 2 Lpm. Interviews with nursing staff revealed inconsistencies in monitoring oxygen flow rates, with responsibility placed on floor nurses to ensure accuracy. The facility's policy required documentation of physician orders for oxygen therapy, but the discrepancy was not addressed, indicating a lapse in adherence to procedures.
The facility failed to post daily nurse staffing information on two days, as required, due to prioritization of other duties by the responsible CNA. The DON and Administrator were aware of the requirement but did not ensure compliance.
Failure to Protect Resident From Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to implement adequate protective interventions after a reported resident‑to‑resident physical altercation. One male resident with dementia, severe cognitive impairment (BIMS score 04), generalized anxiety disorder, major depressive disorder, and a history of verbal aggression toward staff and other residents was sharing a room with another male resident with Alzheimer’s disease and moderate cognitive impairment (BIMS score 11). The cognitively impaired aggressive resident had documented episodes of verbal aggression toward staff and residents in the months prior to the incidents, including multiple resident‑to‑resident verbal aggression events. The roommate had a history of some anger issues at home per family, but non‑physical. On the morning of 02/07/26, staff reported a resident‑to‑resident altercation at the doorway of the shared room. CNA A stated she saw the aggressive resident holding the roommate’s shirt and striking him with a closed fist once to the jaw and once to the chest while the roommate was in his wheelchair trying to exit the room. CNA A reported this to LVN B, including her concern that the two residents could not safely remain together and that the aggressive resident could attack or even kill the roommate. LVN B assessed the roommate, documented that he denied being hit and had no injuries or emotional distress, and documented that the aggressive resident did not recall the incident and had no injuries. The DON and Administrator were notified, but no abuse investigation was initiated because the roommate denied being hit, and the facility relied on his denial despite CNA A’s eyewitness account. The facility did not separate the residents or change rooms; instead, they intermittently monitored and alternated the residents’ presence in the room, with only brief or inconsistent staff presence outside the door and no formal, continuous monitoring documentation during the night shift. In the early morning hours of 02/08/26, a second, more serious altercation occurred between the same two residents. At approximately 4:00 a.m., staff responded to calls for help and found the roommate on the floor with the aggressive resident standing nearby; another CNA reported seeing the aggressive resident holding a bedside table at his waist and later heard him say he would hit the roommate again. Nursing staff assessments documented skin tears to both antecubital areas and the right knee, as well as redness on the bridge of the nose. The roommate stated that the aggressive resident had grabbed him by the arms and pushed him to the floor, and another nurse documented that the roommate reported being pulled from his wheelchair to the floor. Both residents were sent to the hospital for evaluation. The facility’s DON later acknowledged that, in response to the first incident, they had only implemented limited monitoring as reflected in the chart, did not conduct an abuse investigation because the roommate denied being hit, did not perform a room change, and that the second incident could have been prevented had monitoring and protective measures been continued and fully implemented. The surveyors determined that the facility failed to ensure residents were free from abuse and failed to protect the roommate after the initial reported physical altercation, resulting in a second incident with documented injuries and constituting past noncompliance at the Immediate Jeopardy level from 02/07/26 to 02/08/26. The noncompliance was identified as past noncompliance with Immediate Jeopardy beginning on 02/07/26 and ending on 02/08/26. The facility’s failure to protect residents from abuse and to follow its abuse policy for protection during an investigation could place residents at risk of physical harm, mental anguish, and emotional distress. The DON stated that not implementing the abuse policy for protection of residents could negatively impact residents because it could cause injury, and in this case, the only negative impact identified for the roommate was superficial skin tears. The Administrator and DON both confirmed that, at the time of the first incident, they did not identify the event as abuse due to the roommate’s denial of being hit, did not initiate a formal abuse investigation, and relied on limited monitoring rather than separation or one‑to‑one supervision, which did not prevent the second altercation and resulting injuries.
Removal Plan
- Changed Resident #1’s room
- Implemented 15-minute observation checks for Resident #1
- Sent Resident #1 out of the facility
- Implemented a resident-to-resident behavior monitoring tool to identify residents with incidents/behaviors and document corrective actions taken
- Held an ADHOC QAPI meeting addressing the resident-to-resident incident
- Updated Resident #1 care plan to address resident-to-resident aggression
- Updated Resident #2 care plan to address resident-to-resident altercations
- Reviewed care plans for additional identified residents with behaviors to ensure behaviors and interventions were addressed
- Coordinated psychiatric nurse practitioner involvement via email communications identifying residents with behaviors and follow-up
- Ensured psychiatry evaluations occurred for residents with behaviors
- Conducted facility-wide in-service training for all team members on immediate reporting of abuse/injury/neglect/exploitation to the Administrator, reporting resident-to-resident aggression/inappropriate touching, redirecting and keeping residents safe, and placing residents on one-to-one monitoring and keeping them separated
- Provided additional staff training and awareness on immediately reporting abuse to the Administrator and separating residents and implementing one-to-one monitoring after resident-to-resident altercations
- Provided abuse guidance training to the DON and Administrator
Failure to Protect Residents From Repeated Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, specifically in relation to resident-to-resident aggression. Resident #1, an elderly male with dementia, severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, had a documented history of verbal aggression toward staff and other residents. His care plan reflected multiple episodes of resident-to-resident and resident-to-staff verbal aggression prior to the incidents in question. Resident #2, an elderly male with Alzheimer’s disease and moderate cognitive impairment (BIMS score of 11), also had documented behavioral symptoms, including physical and verbal behaviors directed toward others. On 02/07/26, a resident-to-resident altercation occurred between Resident #1 and Resident #2 at the entrance to their shared room. CNA A reported seeing Resident #1 holding Resident #2’s shirt and striking him with a closed fist once in the jaw and once in the chest while Resident #2 was in his wheelchair attempting to exit the room. CNA A stated she yelled for them to stop and called for help, after which LVN B assisted in separating the residents and took Resident #2 to the common area. CNA A reported to LVN B that she had witnessed the punches and warned that the two residents could not safely remain together because Resident #1 was aggressive and could attack Resident #2. LVN B assessed Resident #2, documented no injuries or pain, and recorded that Resident #2 denied being hit and stated only his wheelchair was struck. The DON and Administrator were notified of the incident and of CNA A’s report that Resident #1 had hit Resident #2, but no abuse investigation was initiated because Resident #2 denied being hit. Following the first incident, the facility’s response consisted of limited and inconsistently implemented monitoring. CNA A reported she was posted outside the room for about 10 minutes and did not see anyone else sit outside the room afterward. The DON and RN F stated that monitoring and having an aide posted outside the door were used, but the DON acknowledged there was no documentation of monitoring during the night shift and that the only monitoring was what appeared in the chart. No room change or one-to-one supervision was implemented at that time, and the residents continued to share a room. On 02/08/26 at approximately 4:00 a.m., a second incident occurred in which Resident #2 was found on the floor with bilateral arm and right knee skin tears and redness to the bridge of his nose. Staff interviews and documentation indicated that Resident #2 stated his roommate had grabbed him by the arms and pushed him to the floor, and another aide reported seeing Resident #1 standing over Resident #2 holding a bedside table and saying he would hit him again. Both residents were sent to the hospital for evaluation. The DON later stated that because Resident #2 denied being hit after the first incident, the facility did not initiate an abuse investigation and only implemented limited monitoring, and further acknowledged that the second incident could have been prevented had monitoring been continued. This sequence of events demonstrated the facility’s failure to fully implement its abuse policy requiring protection of residents from harm during abuse investigations and prevention of occurrences of abuse.
Removal Plan
- Completed a room change for Resident #1.
- Implemented 15-minute observation checks for Resident #1.
- Sent Resident #1 out of the facility and cancelled the bed hold.
- Implemented a monitoring tool to identify residents with resident-to-resident behaviors and document actions taken to correct behaviors.
- Held an ADHOC QAPI meeting addressing the resident-to-resident incident.
- Updated Resident #1’s care plan to address resident-to-resident aggression.
- Updated Resident #2’s care plan to address resident-to-resident altercations.
- Reviewed and updated care plans for additional identified residents with behaviors with interventions to address behaviors.
- Coordinated psychiatric nurse practitioner involvement to identify residents with behaviors and follow up.
- Ensured psychiatric evaluations occurred for residents with behaviors.
- Conducted facility-wide in-service training for all team members on immediate reporting of abuse, injury, neglect, and exploitation to the Administrator; reporting resident-to-resident aggression and inappropriate touching; redirecting and keeping residents safe; placing residents on one-to-one monitoring; and keeping residents separated.
- Trained staff to report abuse immediately to the Administrator and to separate residents and implement one-to-one monitoring with any resident-to-resident altercation.
- Trained the DON and Administrator on the abuse guidance policy for preventing, identifying, and reporting.
Failure to Complete and Document Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices by not completing and documenting weekly skin assessments as required by facility policy and physician orders. The resident was an elderly female with epilepsy, dysphagia following a nontraumatic intracerebral hemorrhage, age-related physical debility, and a cognitive communication deficit, with a BIMS score indicating moderate cognitive impairment. Her care plan identified her as having actual or at risk for skin impairment related to incontinence and dependence on staff for toileting and mobility, and included an intervention to follow the facility’s practice for assessing skin and following the skin protocol. Her MDS indicated no current pressure ulcers, venous or arterial ulcers, or other wounds, and a prior skin and wound evaluation documented a healed surgical incision. The resident had an order for weekly skin checks that was discontinued on 09/11/25 and not reordered until 02/24/26, leaving a gap during which no weekly skin assessment orders were in place. Record review showed that her last documented skin and wound evaluation form was completed on 09/30/25, and the DON confirmed that staff had not been doing skin assessments on this resident since sometime in September 2025. The facility’s Skin and Wound Prevention and Management policy required a licensed nurse to conduct and document a routine weekly skin assessment to identify new pressure injuries or other skin concerns, but this was not done for the resident during the identified period. The DON acknowledged that it was not identified that the resident lacked skin assessment orders and that the RN supervisor and DON were responsible for ensuring orders and documentation were in place, and stated that this failure could negatively impact residents by leaving issues untreated in a timely manner.
Inadequate Indication for Antipsychotic (Seroquel) Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary antipsychotic medication. A male resident with severe dementia, generalized anxiety disorder, major depressive disorder without psychotic features, and insomnia was admitted and later discharged from the facility. His Quarterly MDS showed severe cognitive impairment with a BIMS score of 4, no indicators of psychosis, and only limited behavioral symptoms. Despite this, the MDS reflected that he was taking an antipsychotic with an indication noted. The care plan initiated in early September documented a focus on antipsychotic medication related to major depressive disorder and insomnia due to another mental disorder. A consent form for Seroquel 200 mg at bedtime was signed by the responsible party and completed by a physician, listing diagnoses including severe dementia with agitation, major depressive disorder without psychotic features, late-onset Alzheimer’s disease, and unspecified anxiety disorder. The resident’s order summary showed Seroquel 200 mg by mouth at bedtime for dementia with severe agitation and unspecified anxiety disorder, with administration documented on the MAR from early to late January. An order for antipsychotic side effect monitoring every shift was also in place. During interviews, the DON stated that antipsychotics such as Seroquel were not indicated for dementia and was unable to explain why or what negative impact they could have. She reported that the diagnosis associated with Seroquel was later changed to insomnia and that the resident was receiving Seroquel for insomnia, anxiety, and major depressive disorder. A PA stated that the resident was also followed by a mental health provider and that antipsychotics should be used carefully in the elderly, noting both potential benefits and negative impacts. The facility’s policy on psychotropic medication and gradual dose reduction stated that physicians and mid-level providers would use psychotropic medications appropriately with interdisciplinary team involvement, but the survey findings concluded there was not an adequate indication for the use of Seroquel before its administration.
Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident abuse incident to the state agency and appropriate officials within the required 2-hour timeframe. On the date in question, Resident #2 was found on the floor of his room at approximately 4:00 a.m., calling for help. A CNA entered the room and found Resident #2 on the floor with skin tears on both arms and the right knee. Resident #2 stated that his roommate, Resident #1, had pushed or pulled him down. Nursing documentation by LVN D and RN J identified bilateral antecubital skin tears, a right knee skin tear, and a red discoloration on the bridge of the nose, with Resident #2 reporting arm pain but denying emotional distress. Resident #2 was assessed, transferred to the hospital, and later returned with no fractures or critical findings noted in the hospital records. Resident #1’s records showed a history of dementia with severe cognitive impairment (BIMS score of 4), generalized anxiety disorder, major depressive disorder, and insomnia, with documented episodes of verbal aggression toward staff and other residents, and prior resident-to-resident verbal aggression. The care plan and IDT documentation reflected multiple prior behavioral incidents, including resident-to-resident verbal aggression on several dates and an entry on the date of the incident indicating resident-to-resident physical and verbal aggression. An IDT ABC tool completed by LVN D on the date of the incident documented that at 4:00 a.m. Resident #1 was standing over his roommate with a table and was upset, stating he would hit the roommate again. Resident #2’s records reflected Alzheimer’s disease with moderate cognitive impairment (BIMS score of 11) and a history of behavioral symptoms, including physical and verbal behaviors directed toward others. His care plan noted prior resident-to-resident physical altercations on the day before and the day of the incident. The Administrator, who served as the abuse coordinator, stated she was notified by LVN D at approximately 5:00 a.m. of the altercation and injuries but did not report the allegation to HHSC until 5:00 p.m., well beyond the 2-hour requirement. She acknowledged that the altercation should have been reported within 2 hours and that facility policy, consistent with HHSC PL 19-17, required alleged or suspected abuse to be reported immediately, but not later than 2 hours after the allegation is made, when the events involve abuse or result in serious bodily injury. The Administrator stated she reported late because she was busy conducting interviews.
Failure to Follow Enhanced Barrier Precautions for Resident on Infection Control Protocol
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for one resident who was under Enhanced Barrier Precautions (EBP). Specifically, staff members did not consistently don the required personal protective equipment (PPE) before entering the resident's room and providing care. Video footage confirmed that on two separate occasions, a licensed vocational nurse (LVN) and a certified nursing assistant (CNA) entered the resident's room without wearing the appropriate gown and gloves, despite clear signage and available PPE supplies outside the room. The resident involved was an older male with multiple complex medical conditions, including Parkinson's disease with dyskinesia, type 2 diabetes mellitus, and a feeding tube due to dysphagia. His care plan and medical records indicated the need for EBP, which required staff to wear gowns and gloves during high-contact care activities, such as medication administration and incontinent care. Observations showed that PPE and hand hygiene supplies were accessible, and signage was posted to instruct staff on the required precautions. Interviews with various staff members, including CNAs, LVNs, and nursing leadership, revealed that they were aware of the EBP requirements and the importance of PPE use to prevent infection and cross-contamination. Despite this knowledge and ongoing in-service training, the observed failures by the LVN and CNA to don PPE before providing care to the resident constituted a breach of the facility's infection control policy.
Failure to Adhere to Infection Control Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not adhere to the required Enhanced Barrier Precautions (EBP) when providing care to a resident with a PEG tube. On multiple occasions, LVN A entered the resident's room without donning the appropriate personal protective equipment (PPE), specifically a gown and gloves, while performing high-contact activities such as applying gauze to the PEG tube. This non-compliance with EBP was observed on specific dates and times, as captured by video footage from the resident's electronic monitoring device. The resident involved was an elderly male with severe cognitive impairment, requiring a feeding tube due to conditions such as Parkinson's disease and dysphagia. The resident's care plan and order summary explicitly required the use of EBP, which mandates the use of gown and gloves during high-contact activities to prevent the transmission of infections. Despite the presence of signage and available PPE supplies, LVN A failed to follow these guidelines, as confirmed by video evidence and interviews with facility staff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that LVN A had been trained on infection control and EBP guidelines. Both the ADON and DON acknowledged the failure of LVN A to adhere to the facility's infection control policy, which could potentially place residents at risk of infection. The facility's policy and training records indicated that LVN A had completed the necessary competencies and in-service training related to infection control and PPE usage.
Failure to Maintain Sanitary Environment in Resident's Shower
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in room [ROOM NUMBER], as evidenced by the presence of a white dirty towel with brown colorations in the private shower area. This issue was observed on two separate occasions, a week apart, indicating a lack of effective cleaning and oversight. Housekeeping staff, including HK J and HK S, reported that rooms were cleaned daily, including the shower areas, but no concerns had been raised about room [ROOM NUMBER]. Despite the cleaning routine, the dirty towel remained in the shower, suggesting a lapse in the cleaning process or communication among staff. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that neither was aware of the issue until it was brought to their attention. Both acknowledged that the towel should not have been left in the shower for an extended period. The DON confirmed that there was no negative outcome to the residents from the dirty towel, but emphasized the importance of maintaining a clean environment. The facility's Physical Environment policy, revised in January 2023, mandates a safe, functional, sanitary, and comfortable environment, which was not upheld in this instance.
Inaccurate Documentation of Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, as staff continued to log temperatures on the Medication Administration Record (MAR) for the resident's personal refrigerator even after it had been taken home by the resident's family. The resident, a male with severe cognitive impairment and multiple diagnoses including Parkinson's disease and type 2 diabetes, had a care plan that did not include the personal refrigerator after it was removed from the facility. Despite this, the MAR continued to reflect recorded temperatures for the refrigerator from the time it was taken home until a later date, indicating a lapse in accurate documentation. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed a lack of awareness regarding the continued documentation of refrigerator temperatures after its removal. The DON acknowledged that the order for temperature checks should have been discontinued once the refrigerator was no longer present, but was unable to explain why the documentation persisted. The facility's administrator also confirmed that the order should have been discontinued and expressed uncertainty about how temperatures were recorded without the refrigerator. The facility's policy on personal refrigerators did not provide specific guidance on accurate record-keeping, contributing to the deficiency.
Infection Control Deficiency Due to PPE Non-Compliance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two licensed vocational nurses (LVNs) who did not adhere to enhanced barrier precautions (EBP) when providing care to residents. Specifically, LVN A did not don a gown while caring for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, despite the resident being on EBP. This resident had severe cognitive impairment and required a feeding tube due to dysphagia. The facility had signage indicating the need for gowns and gloves during high-contact activities, but LVN A only wore gloves, citing a lack of recent training and misunderstanding of the requirements. Similarly, LVN B failed to wear a gown while providing care to another resident with a midline catheter, who was also on EBP. This resident had intact cognition and was being treated for Parkinson's disease and type 2 diabetes. Despite the presence of signage and available PPE, LVN B only wore gloves during the procedure. LVN B initially claimed unawareness of the EBP status and later admitted to forgetting to wear the gown, indicating a lapse in adherence to the facility's infection control policy. The facility's infection prevention and control program required the use of gowns and gloves during high-contact activities with residents on EBP, as outlined in their policy. However, both LVNs failed to comply with these guidelines, potentially placing residents at risk for cross-contamination and infection. The facility had provided training on EBP, but the incidents suggest a need for reinforcement and consistent adherence to infection control protocols.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to have physician orders for enhanced barrier precautions (EBP) in place at the time of admission for two residents, both of whom had invasive devices that necessitated such precautions. Resident #4, a male with a history of dysphagia and a feeding tube, was admitted without EBP orders despite the presence of signage and personal protective equipment (PPE) indicating the need for such precautions. Similarly, Resident #5, who also had a feeding tube and severe cognitive impairment, was admitted without EBP orders, although PPE and signage were present. The absence of EBP orders was identified during a survey, and the Assistant Director of Nursing (ADON) confirmed that the orders were missing from the residents' charts. The ADON acknowledged that the admitting nurse was responsible for inputting these orders, and the oversight was attributed to a lack of formal training and reliance on on-the-job training. The Director of Nursing (DON) also confirmed the deficiency, noting that the facility's policy required EBP orders to be in place, but this was not followed. Both the ADON and DON recognized the importance of having EBP orders to ensure staff compliance with infection control measures. The deficiency was noted to potentially place residents with indwelling devices at risk of developing infections, as the absence of formal orders could lead to lapses in precautionary measures. The facility's failure to input EBP orders was attributed to a lack of adherence to policy and insufficient training for staff responsible for order entry.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the storage of foods brought to residents by family and other visitors, specifically for a resident with a personal refrigerator. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not maintain complete documentation of temperature checks for the resident's personal refrigerator throughout October. This oversight could potentially expose residents with personal refrigerators to the risk of foodborne illness. The resident in question was a male with Parkinson's disease, type 2 diabetes, and dysphagia, who had a feeding tube and was cognitively intact. The resident's care plan indicated that the personal refrigerator was for family use, and the temperature log was to be updated daily. However, the temperature log for October showed entries only for a few days, and the Director of Nursing (DON) confirmed that the staff did not follow the facility's policy. The DON acknowledged that the night nurses were responsible for checking and logging the refrigerator's temperature but admitted there were gaps in the log. Interviews with the resident's family member revealed that the refrigerator was used for the resident's pleasure feeding items, contradicting the DON's statement that it was for family use. The facility had previously conducted in-service training on refrigerator monitoring, but the deficiency persisted.
Failure to Maintain Prescribed Oxygen Rate for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not ensuring the resident received oxygen at the prescribed rate. Resident #49, a 76-year-old male with severe cognitive impairment and diagnoses including congestive heart failure and pleural effusion, was prescribed continuous oxygen therapy at 2 liters per minute (Lpm) via nasal cannula. However, during an observation, the resident was found to be receiving oxygen at 3 Lpm, which was not in accordance with the prescribed rate. Interviews with the nursing staff revealed inconsistencies in monitoring and maintaining the correct oxygen flow rate. LVN B, who was responsible for Resident #49, stated that she checked the oxygen rate at the beginning of her shift and found it set at 2 Lpm, but later it was observed at 3 Lpm. She was unsure how the rate changed and mentioned that the resident was not known to adjust the oxygen settings himself. Another nurse, LVN C, confirmed that it was the responsibility of the floor nurses to ensure the accuracy of oxygen rates, and she had not known the resident to adjust the rate independently. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized that nurses were responsible for checking oxygen settings during rounds and whenever they entered the resident's room. The facility's policy on oxygen administration required physician orders for oxygen therapy, including the flow rate, to be documented in the Treatment Administration Record (TAR) and/or Medication Administration Record (MAR). Despite this policy, the discrepancy in the oxygen flow rate for Resident #49 was not addressed, indicating a lapse in adherence to the facility's procedures and professional standards of practice. This failure to maintain the prescribed oxygen rate could potentially place residents at risk for respiratory distress.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors with all required information for two of the four days reviewed. Specifically, on 10/2/24 and 10/3/24, the daily staffing information was not updated and posted in a prominent location as required. During a walkthrough on 10/3/24, the State Surveyor observed that the Direct Care Staff sign had not been updated since 10/1/24. This oversight could potentially place residents, families, and visitors at risk of not being informed about the census and the number of staff working each day to provide care on all shifts. Interviews conducted during the investigation revealed that CNA A, who was responsible for updating the staffing information, prioritized resident care and other duties over updating the staffing information. She acknowledged that she was aware of the requirement to update the staffing information daily but did not do so on 10/2/24 due to other work commitments. The Director of Nursing (DON) confirmed that CNA A was informed of her responsibilities and that the RN supervisors were responsible for updating the information on weekends. However, the DON admitted that there was no one currently ensuring the staff information was being posted. The Administrator also acknowledged the regulatory requirement for daily posting but assumed the information was being updated without verifying it.
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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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