Arbor View Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Kerrville, Texas.
- Location
- 1213 Water St, Kerrville, Texas 78028
- CMS Provider Number
- 455724
- Inspections on file
- 57
- Latest survey
- September 7, 2025
- Citations (last 12 mo.)
- 45 (3 serious)
Citation history
Health deficiencies cited at Arbor View Nursing & Rehabilitation during CMS and state inspections, most recent first.
A nurse administered a set of medications intended for one resident to another, including multiple controlled substances and a dangerously high dose of an antipsychotic, after preparing medications for two residents at the same time and confusing the medication cups. The affected resident, who had a complex medical history, became unresponsive and required ICU care for hypothermia, hypotension, and metabolic encephalopathy. The nurse did not follow established medication administration protocols, leading to this significant error.
Two residents experienced deficiencies in medication handling: one had refused morning medications that were improperly stored in a medication cart instead of being disposed of, while another had a dose of hydrocodone signed out but not administered or properly wasted with a witness and documentation. Staff misunderstood or failed to follow procedures for medication disposal and documentation, including for controlled substances.
A resident with multiple medical conditions experienced a medication error when an LVN administered another resident's medications and failed to document the error, assessments, vital signs, notifications, or the hospital transfer in the medical record. Hospital records were not uploaded into the electronic record, and the MAR inaccurately reflected medication administration. Staff interviews revealed confusion about documentation procedures and responsibilities.
The facility did not ensure that residents were protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, resulting in a deficiency related to resident safety and well-being.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an increased risk of incidents.
The facility did not provide RN coverage for at least 8 consecutive hours per day, 7 days a week, as required by policy. On several days, there was no RN coverage at all, and on other days, RN coverage was less than 8 hours. The Administrator confirmed these lapses and could not provide additional documentation to show compliance.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation, including unlabeled beverage pitchers, improper stacking of raw proteins over ready-to-eat foods, undated and unidentified frozen items, a dirty ice machine, and improper placement of sanitizing buckets and personal beverages near food prep areas. Staff interviews confirmed knowledge of proper procedures, but observed practices did not meet facility policy or professional standards.
A facility with 179 licensed beds did not employ a qualified social worker on a full-time basis, as required. The Administrator reported that the last full-time social worker's employment ended and the position remained vacant, with only a remote, as-needed social worker available. Facility policy confirmed the need for a full-time social worker for facilities of this size.
The facility did not maintain an effective pest control program, as evidenced by the presence of flies, gnats, and a roach in resident rooms and other areas. Staff and resident interviews confirmed that pests interfered with meals and were a recurring issue, particularly during warmer months. Facility records also documented prior concerns about bugs in resident rooms, and the pest control policy was not effectively implemented.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, leading to inadequate staff training and oversight and placing residents at risk for harm.
The facility did not report multiple incidents of abuse, neglect, and serious injuries—including a resident-to-resident altercation resulting in a head laceration, unwitnessed falls with fractures, and verbal abuse—within the required timeframe to the State Survey Agency and law enforcement. Staff and administration either failed to recognize the need for immediate reporting or were unaware of the specific requirements, leading to delays and omissions in mandated notifications.
Three nurse aides provided resident care without current or valid CNA certification, including one with an expired certification, one who had not yet obtained certification after completing training, and one who worked full-time without progressing toward certification. Facility staff, including HR and the ADM, acknowledged lapses in verifying and maintaining required credentials, contrary to facility policy.
Two residents experienced significant medication errors when staff failed to follow physician orders and medication parameters for hypertension management. One resident did not receive a prescribed hypertension medication as ordered, with staff withholding doses based on parameters not specified by the physician and without proper documentation or provider notification. Another resident received antihypertensive medication outside of the prescribed blood pressure parameters, and the care plan did not address the resident's hypertension diagnosis. The DON was unaware of these errors, and facility policy requiring adherence to medication administration standards was not followed.
Surveyors found that two medications requiring refrigeration were stored in a medication cart instead of a refrigerator, contrary to labeling and facility policy. Additionally, a medication cart was left unlocked and unattended in a hallway with residents nearby, and an LVN acknowledged responsibility for not securing the cart as required.
A resident with insomnia and moderate cognitive impairment experienced ongoing sleep disruption and discomfort due to a broken window blind that was not repaired despite repeated requests. Staff interviews and observations confirmed that broken blinds were a frequent problem, and the issue persisted for several days, impacting the resident's comfort and privacy.
A resident with severe cognitive impairment and liver disease was prescribed buspirone, a psychotropic medication, without a documented psychiatric or mood disorder diagnosis. The DON confirmed that such medications require an associated diagnosis, and facility policy mandates documented indications for use. This resulted in a failure to ensure the resident's drug regimen was free from unnecessary medications.
The facility did not investigate or report two incidents as required: one involving a resident verbally abusing another in the dining room, and another where a resident with severe cognitive impairment sustained a hip fracture after an unwitnessed fall. In both cases, staff failed to follow protocols for investigation and timely reporting to the administrator and state agency.
Two residents' MDS assessments did not accurately reflect their active diagnoses, with one resident's PTSD and another's depression and anxiety omitted despite supporting documentation and prescribed psychotropic medications. The MDS nurse and DON both acknowledged the expectation that all active diagnoses should be included in the MDS, as required by facility policy.
A resident with severe cognitive impairment and multiple ADL assistance needs did not have a care plan that addressed their specific self-care performance requirements. The care plan lacked detailed interventions for tasks such as transfers, bed mobility, and eating, leading staff to rely on verbal updates and the Kardex for guidance. This omission was confirmed by nursing leadership and was not in accordance with facility policy.
A respiratory therapist failed to perform a complete lung assessment before administering an albuterol inhaler to a resident with pulmonary disease and heart failure, only listening to the top front lobes and omitting the back and other lobes, despite being trained to assess all areas. Facility policies lacked specific guidance on respiratory assessment.
The facility did not maintain accurate and complete medical records for two residents. One resident's admission record, care plan, and MDS lacked any medical diagnoses despite multiple medication orders referencing specific conditions, and another resident's skin assessment failed to document a forehead laceration with staples, even though monitoring orders were present. The DON and MDS nurse confirmed expectations for accurate documentation and timely entry of diagnoses.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A resident with severe cognitive impairment who required partial to moderate assistance with bathing did not receive scheduled showers, as evidenced by only one recorded shower during their stay. The resident was not included on the shower schedule, and staff could not confirm regular bathing, resulting in inadequate personal hygiene care.
Several residents with complex medical needs were not consistently provided with prescribed snacks at bedtime or as ordered, due to disorganized snack distribution, lack of labeling, incomplete documentation, and unclear staff responsibilities. Staff interviews and observations revealed that snacks were often left unattended at the nurse's station, sometimes taken by other residents, and not always delivered to those with specific dietary orders.
Three residents with complex medical needs did not have their physician-ordered snacks and supplements accurately documented on the MAR/TAR, resulting in missing or incomplete records of administration. Staff interviews revealed confusion about documentation responsibilities and unfamiliarity with the electronic record system, leading to inconsistencies in providing and recording prescribed nutritional interventions.
A medication aide entered a resident's room without knocking, interrupting an interview and disregarding the resident's expressed preference for privacy and a closed door. The resident, who had cognitive impairment and physical disabilities, reported that staff frequently entered without knocking and did not close the door, which was bothersome and impacted his sense of privacy. Facility leadership and policy confirmed the expectation to respect resident privacy by knocking before entry.
A resident with severe cognitive impairment and poor safety awareness was found with two disposable razors in his room, despite facility protocols requiring razors to be handled only by staff and disposed of in a sharps container. Staff interviews confirmed that residents in the memory care unit should not have unsupervised access to razors due to the risk of harm to themselves or others.
The facility failed to ensure the Dietary Manager had the required certification or qualifications for the role, hiring an individual with only an associate degree in culinary arts and no CDM certification. The Administrator and HR staff did not verify or follow up on the necessary credentials, and the DM had not enrolled in the certification program. This deficiency was identified for the only dietary staff reviewed, with the dietician visiting only twice a month.
A dietary aide working as a cook did not have a valid Texas Food Handler's Certificate, despite being informed multiple times of the requirement. The aide had been moved from housekeeping to the kitchen due to staffing needs and had not completed the necessary course, which was not identified by the administrator until after the deficiency was noted.
Two residents had incomplete and inaccurate medical records, with psychiatric provider diagnoses not reflected on their official diagnosis lists or face sheets. One resident's diagnoses of delusions, neuropathy, and dementia with behaviors were omitted, while another's Major Depressive Disorder was not documented despite being treated for depression. The DON confirmed these omissions and attributed them to a recent change in electronic health record systems.
A former LVN accessed the medical records of several residents after being removed from the facility, leading to a breach of confidentiality. The incident was discovered when an anonymous individual, informed by the LVN, contacted a resident's family with sensitive information. Interviews revealed a lack of a specific process for promptly removing access to electronic medical records for staff no longer employed.
A resident with severe dementia was recorded by a visitor, and the video was posted on social media, causing distress to the resident's family. The facility was aware of the video but did not inform the family, as they determined no abuse occurred. The facility lacked a policy on visitor recordings, contributing to the deficiency in maintaining the resident's dignity and privacy.
The facility failed to store and prepare food safely, with ground beef and eggs improperly thawed and stored at unsafe temperatures. Malfunctioning refrigeration equipment led to the use of a temporary refrigerator that did not maintain safe temperatures. Staff were unaware of proper food safety protocols, resulting in a decision to cater meals to prevent foodborne illnesses.
The facility failed to maintain a safe and comfortable environment in Wing III due to a malfunctioning air conditioning system and a damaged light fixture. Observations showed high temperatures, with a portable AC unit unable to cool the area effectively. Despite residents not complaining about the heat, the ADM and DON acknowledged risks of overheating and dehydration. Additionally, a light fixture in a resident's room posed a risk of falling. The facility's maintenance policy requires maintaining systems in working order, but no extra staff were scheduled to ensure resident comfort.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. During a 91-day review, it was found that there was no RN coverage on several specific dates, despite the facility having 78 residents. The Administrator provided a digitally shared calendar indicating RN hours, but it was created after the fact with no supporting evidence. No RN Coverage policy was provided.
An exterior door on the 300-hallway was found open and unlatched without an alarm sounding, leading to potential hazards for residents. The door, which led to a parking lot near a river and busy road, was not typically used by staff or residents. Staff were unaware of the open door, and it was suggested it might have been left open during maintenance activities. The ADM and DON acknowledged the risks, including elopement and unauthorized entry, highlighting a failure to maintain a safe environment as per facility policy.
A resident with dementia and hypertension did not receive prescribed metoprolol tartrate 25 mg on multiple occasions due to the medication being marked as unavailable. Despite the medication being in the emergency kit, it was not accessed, and there was a lack of communication about its unavailability. The facility's policy for timely medication administration was not followed, leading to this deficiency.
The facility failed to properly dispose of garbage and refuse, with a damaged drain plug on one dumpster allowing ant entry and scattered debris around the area. The Administrator and Maintenance Supervisor acknowledged the issues, attributing some debris to a recent storm and confirming the need for cleaning and plug replacement.
A resident with Parkinson's disease and dementia was left unattended in her wheelchair, resulting in a fall and head injury. The resident had a history of poor trunk control and required frequent repositioning, which was not adequately provided, leading to the incident.
The facility failed to maintain kitchen sanitation standards, with observations revealing grease, dirt, and debris under refrigerators and the ice chest, food stored on the floor, and mice droppings near the pantry. The Food Service Supervisor acknowledged the issues and had been addressing them since being hired three weeks prior. The local health department's inspection report also noted these concerns and recommended immediate cleaning and resolution.
The facility failed to dispose of garbage and refuse properly as 2 of 3 dumpsters were missing drain plugs. The Maintenance Director, hired three weeks prior, had not checked the plugs, which were necessary to prevent liquids from attracting pests. The facility's policy did not address the requirement for plugs.
The facility failed to maintain an effective pest control program, resulting in the presence of mice and rats in the kitchen. Observations revealed dried mouse droppings, sticky traps, and a live mouse trap in the ceiling. Staff confirmed ongoing issues, and the pest control company had been making regular visits. Despite efforts to address the problem, the presence of pests indicated a failure in the pest control program.
The facility failed to coordinate assessments with the PASARR program for a resident with severe intellectual disabilities and other diagnoses. The NFSS request for therapy services was not submitted timely, initially containing a typed signature instead of a unique original signature, leading to a denial of the request. Interviews confirmed that the responsible MDS staff had been let go, and the therapist admitted to the signature error.
Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when a licensed vocational nurse (LVN) administered a set of medications intended for one resident to another resident. The nurse prepared medications for two residents simultaneously on top of the medication cart and confused the medication cups, resulting in the wrong resident receiving multiple medications not prescribed to her, including two Schedule IV controlled substances and a dose of quetiapine (Seroquel) 32 times higher than prescribed. The nurse realized the error immediately after administration and reported it to the Director of Nursing (DON) and hospice staff. The affected resident had a medical history including epilepsy, hypotension, cardiomyopathy, and schizophrenia. Following the administration of the incorrect medications, the resident initially presented with normal vital signs but soon became lethargic, unresponsive to voice or touch, and developed hypotension. Emergency services were called, and the resident was transferred to the hospital, where she was treated in the ICU for hypothermia, hypotension, and metabolic encephalopathy. Hospital records confirmed the administration of multiple medications not prescribed to the resident, as well as a positive urine drug screen for opioids, tricyclic antidepressants, and benzodiazepines. Interviews and record reviews revealed that the LVN did not follow facility policy or the five/six rights of medication administration, which require preparing and administering medications to one resident at a time and verifying resident identity. The DON confirmed that the nurse failed to adhere to these protocols, leading to the error. The incident was self-reported by the facility due to the serious injury resulting from the medication error.
Failure to Properly Dispose and Document Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services for two residents, resulting in deficiencies related to medication administration and disposal. For one resident with severe dementia and on hospice care, morning medications including Depakote, fluoxetine, lisinopril, Provera, and lorazepam were prepared and mixed with pudding, but the resident refused to take them. The medication aide placed the cup with the mixed medications, labeled with the resident's name, in the medication cart instead of disposing of them as required. The aide believed it was acceptable to keep the medications as long as the cup was labeled, and this misunderstanding was confirmed during interviews. The licensed vocational nurse was informed of the refusal but did not ensure the medications were properly wasted, which is necessary to prevent medication errors. In another case, a resident with multiple diagnoses including epilepsy and schizophrenia was prescribed hydrocodone-acetaminophen for pain management. The nurse signed out a dose of hydrocodone on the narcotic record but did not administer it, instead discarding it in the sharps container without a witness or proper documentation. The nurse admitted to not following the required procedure for wasting controlled substances, which includes having another nurse witness the disposal and documenting it with double signatures. The Director of Nursing confirmed that the narcotic record did not accurately reflect the time the medication was pulled and that the medication was not administered as documented. Facility policy requires that medications be administered and disposed of according to professional standards, including proper identification, documentation, and witnessing of controlled substance disposal. The observed failures to follow these procedures for both regular and controlled medications led to the deficiencies cited in the report.
Failure to Maintain Accurate and Complete Medical Records Following Medication Error
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, a medication error occurred when an LVN administered another resident's medications to a resident with a history of epilepsy, hypotension, cardiomyopathy, and schizophrenia. The LVN did not document the medication error, the medications given, assessments, vital signs, change of condition, notifications to the physician and responsible party, follow-up orders, or the resident's transfer to the hospital by EMS in the resident's permanent medical record. Instead, the LVN wrote a separate handwritten statement that was not included in the official medical record. Additionally, the facility failed to upload the resident's hospital records from the hospital stay following the medication error into the permanent medical record. Staff interviews revealed confusion about the process and responsibility for uploading hospital records, with no designated medical records staff and inconsistent procedures for handling and uploading documents. The ADON was identified as responsible for uploading records, but there was no clear or timely process in place, and hospital records were not available in the electronic record for review several days after the resident's return. The LVN also inaccurately documented medication administration in the Medication Administration Record (MAR), indicating that the resident received her prescribed medications when, in fact, she had received another resident's medications. The LVN admitted to documenting medication administration as medications were removed from packaging rather than after administration, contrary to facility policy. The DON and other staff acknowledged the lack of proper documentation and the importance of accurate records for continuity of care, but facility policy and training were not consistently followed.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as required. Record reviews showed that there were multiple days within a six-month period where no RN services were provided at all, specifically on five separate dates. Additionally, there were several other days where RN coverage was present but did not meet the minimum requirement of 8 consecutive hours, with coverage ranging from as little as 2 hours to just under 8 hours on various dates. The facility census during this period was 76 residents daily. Interviews with the Administrator confirmed the lack of RN coverage on certain days, and the Administrator was unable to provide any additional records to demonstrate compliance for the dates in question. The facility's own policy, dated 05/30/2025, required RN services for at least 8 consecutive hours per day, 7 days per week. The Administrator acknowledged the importance of daily RN coverage for resident assessments but could not explain the lapses, noting that some of the incidents occurred before his tenure.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service practices within the facility. Beverage pitchers on all three beverage carts used during dinner meal service were not labeled with the contents or the date of preparation. The Dietary Manager confirmed that all beverage pitchers should be labeled and that the staff member responsible had been trained on this procedure. Additionally, in one of the freezers, raw ground beef was stacked on top of raw chicken drumsticks, which in turn was stacked on top of pasta, contrary to safe food storage practices. Two products in the freezer were also found to be undated and unlabeled, with staff unable to identify one of the items. Further observations revealed that the ice machine had black spots and rust inside, and the Dietary Manager admitted to only cleaning the outside of the machine. A fan blowing towards the 3-compartment sink used for cleaning dishes was found to be dirty and had debris, including a string, blowing from it. Sanitizing buckets were stored near food products such as thickener, bananas, and potatoes, and a personal beverage was found on a shelf below a food preparation table alongside food and sanitizing buckets. Staff interviews indicated some confusion about the appropriateness of these practices, with conflicting statements about health department guidance. Additionally, a dietary aide failed to check the temperature of milk served at breakfast, and the Dietary Manager acknowledged oversight of this process. Facility policies and the FDA Food Code require proper labeling, dating, and storage of food, as well as regular cleaning of equipment and separation of chemicals from food items. Staff interviews confirmed awareness of these requirements, but the observed practices did not align with established standards and facility policies.
Failure to Employ Full-Time Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, licensed for 179 beds, failed to employ a qualified social worker on a full-time basis as required for facilities with more than 120 beds. Record reviews confirmed the facility's licensed capacity, and interviews with the Administrator revealed that the last full-time social worker's employment ended on 05/20/2025, and the position had not been filled since. The Administrator indicated a belief that the requirement for a full-time social worker was based on census rather than licensed beds and stated that only a remote, as-needed social worker was available, who did not work full-time for the facility. Facility policy also reflected the requirement for a full-time social worker for facilities of this size.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of flies, gnats, and a roach in resident areas and other parts of the building. Observations included black flying insects around a resident's breakfast tray, which interfered with the resident's ability to eat and drink. Staff interviews confirmed that gnats were present in several rooms, particularly during the summer months, and that the primary method of control was to remove meal trays quickly. Staff reported pest sightings to their supervisors, but there was no indication of a systematic or effective pest control response prior to the recent intervention. Additional observations included a live roach in another resident's room and multiple flies in the medication room. A review of facility records showed a previous grievance regarding a bug in a resident's room. The facility's pest control policy required an effective program, but the presence of pests and staff accounts indicated that the program was not adequately preventing or addressing infestations at the time of the survey. Residents affected included those with moderate to severe cognitive impairment, some of whom were unable to communicate their concerns about pests.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have adequate systems in place to ensure the protection of residents from these types of mistreatment. There was a lack of clear guidance and enforcement regarding the prevention of abuse, neglect, and theft, which resulted in insufficient staff training and oversight. The absence of comprehensive policies and procedures contributed to an environment where residents were at risk for harm.
Failure to Timely Report Abuse, Neglect, and Injuries to Authorities
Penalty
Summary
The facility failed to ensure that all allegations and incidents involving abuse, neglect, and misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency and law enforcement as required. Multiple incidents involving several residents were not reported within the mandated timeframe. In one case, a resident with severe cognitive impairment suffered a scalp laceration requiring 12 staples after a resident-to-resident altercation. The incident was not reported to law enforcement or the State Survey Agency until approximately nine hours after it occurred, despite staff and leadership being aware of the event and its severity. Interviews revealed that staff and administration were either unaware of the reporting requirements or did not consider the injury to be serious enough to warrant immediate reporting. Another incident involved a resident with severe dementia who experienced an unwitnessed fall resulting in a femur fracture. The fall was not reported to the State Survey Agency, as the facility determined internally that the incident did not meet the criteria for self-reporting, despite the resident's significant injury and cognitive impairment. The administrator stated that only incidents involving abuse or neglect were brought to his attention and that there was no specific policy for self-reporting incidents or accidents, relying instead on state guidelines. Additional deficiencies included a witnessed incident of verbal abuse by a cognitively intact resident toward another resident, which was documented in progress notes but not reported or investigated as potential abuse. Staff interviews indicated uncertainty about whether the incident qualified as abuse and whether it was reported to supervisors or the abuse coordinator. Another resident sustained an injury of unknown source after an unwitnessed fall, resulting in a femur fracture, but the incident was not reported as required. The facility's own policies and state regulations mandate immediate reporting of such incidents, but these were not followed in the cases reviewed.
Failure to Verify and Maintain Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that three nurse aides (CNA AB, NA G, and NA AH) had current and valid nurse aide certifications prior to and during their employment while providing resident care. CNA AB's nurse aide certification had expired, yet she continued to work and provide care to residents. Both the Administrator and Human Resources (HR) staff acknowledged oversight in verifying and maintaining up-to-date certifications. CNA AB admitted to letting her certification lapse and was in the process of renewal while still working. NA G, although having completed a nurse aide training program, had not yet obtained certification and was performing CNA duties under the supervision of a certified aide, contrary to facility and regulatory requirements. The Director of Nursing (DON) and Administrator confirmed that NA G was working on the floor as a nurse aide, and the corporate nurse stated she should have only been working as a hospitality aide until certified. NA AH was also found to be working as a full-time CNA with an expired nurse aide registry status. HR reported that NA AH had not continued her education or progress toward certification after being hired and had been repeatedly informed of the need to become certified. Despite this, NA AH worked full-time hours as a CNA until her employment ended. The facility's job description and policy required all nurse aides to be certified and for HR to verify and maintain current licensure status, but these procedures were not followed for the three individuals identified.
Failure to Prevent Significant Medication Errors for Residents with Hypertension
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were reviewed for unnecessary medications. For one resident with essential hypertension and hypertensive heart disease, the physician's order required administration of Entresto twice daily. However, the medication was withheld on multiple occasions by a medication aide, who applied blood pressure parameters from other hypertension medications to Entresto, despite the absence of such parameters in the physician's order. There was no documentation in the resident's progress notes explaining why Entresto was withheld, and the prescribing provider was not always notified when the medication was not administered. Interviews with staff revealed that the medication aide held the Entresto based on her own interpretation of blood pressure readings and existing parameters for other medications, rather than following the specific physician's order for Entresto. The licensed vocational nurse confirmed instructing the aide to hold the medication in some instances due to low blood pressure, and acknowledged that the physician's order should have included administration parameters. The Director of Nursing stated that if medications are held due to nursing judgment, a progress note should be documented and the provider notified, which did not occur in these cases. For another resident with severe cognitive impairment and hypertension, the care plan did not address the hypertension diagnosis. The resident had an order for Metoprolol with specific parameters to hold the medication if blood pressure or pulse was below certain thresholds. Despite this, staff administered Amlodipine Besylate to the resident on numerous occasions when blood pressure readings were outside the prescribed parameters. The Director of Nursing was unaware of these out-of-parameter administrations and stated that her expectation was for parameters to be followed and for necessary parties to be informed if medications were given outside of parameters. Facility policies required adherence to medication administration standards and reporting of medication issues, which was not followed in these instances.
Improper Storage and Security of Medications
Penalty
Summary
Surveyors observed that two medications requiring refrigeration, Latanoprost ophthalmic solution and promethazine suppositories, were stored in a medication cart drawer instead of the medication refrigerator. Both medications were labeled with blue stickers indicating that refrigeration was required. During an interview, the Assistant Director of Nursing confirmed that these medications should have been stored in the medication refrigerator and acknowledged that improper storage could result in harm to residents. The facility's policy also specifies that all medications requiring refrigeration must be stored in designated refrigerators located in the pharmacy and medication rooms. Additionally, the 300-hall medication cart was found unlocked and unattended in the hallway near the nurses' station, with four residents present in the immediate area. No staff were present during the observation period, and no residents were seen accessing the cart. Upon returning, an LVN admitted responsibility for the unlocked cart and stated that facility policy requires the cart to be locked when not in use. The facility's policy further mandates that medications must be under direct observation or locked during medication pass.
Failure to Maintain Functional Window Blinds for Resident Comfort and Privacy
Penalty
Summary
A deficiency was identified when a resident's window blind was found to be broken and unable to fully cover the window, resulting in the resident being exposed to light from the parking lot at night, which disrupted her sleep. The resident, who had a history of insomnia, major depressive disorder, and generalized anxiety disorder, and was assessed as having moderate cognitive impairment, reported that she had requested staff to fix the blinds for more than a week without resolution. Multiple interviews with staff, including nursing assistants, housekeeping, and maintenance, confirmed that broken blinds were a recurring issue in the facility, and that the problem had been reported to supervisors and maintenance, but remained unresolved for this resident. Observations over several days confirmed that the blinds in the resident's room remained broken, and staff acknowledged that functioning blinds were important for resident privacy and comfort. The facility's own policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, but this was not achieved in this instance, as the resident continued to experience discomfort and lack of privacy due to the unresolved maintenance issue.
Psychotropic Medication Prescribed Without Documented Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs without adequate indications for use, as evidenced by the case of a resident who was prescribed a psychotropic medication without a documented diagnosis to support its use. Record review showed that the resident, who had severe cognitive impairment and a history of alcoholic cirrhosis with ascites and hepatitis C, was ordered buspirone for 'mood' without a corresponding psychiatric or mood disorder diagnosis documented in the medical record. The resident's care plan and medication orders included multiple psychotropic medications, but the required diagnosis for buspirone was not present. During an interview, the DON confirmed that psychotropic medications should have an associated diagnosis, and facility policy requires that such medications be used only when there is a specific, diagnosed, and documented condition. The lack of a documented indication for the use of buspirone in this resident's record constituted a failure to comply with facility policy and regulatory requirements regarding the use of psychotropic medications.
Failure to Investigate and Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate and report two separate incidents involving allegations of abuse and injury, as required by state law and facility policy. In the first incident, a female resident with a history of mood disorders and dementia verbally abused another resident in the dining room, using derogatory language and following the other resident around. The event was documented in a progress note by an LVN, but there was no evidence of an incident report or notification to the State Survey Agency. Interviews with staff revealed uncertainty about whether the incident was reported or investigated, and the Director of Nursing was unaware of the event. In the second incident, a male resident with severe cognitive impairment and a history of falls was found on the floor in another resident's room, complaining of back pain. Although initially assessed as having no major injury, the resident later complained of leg pain and was diagnosed at the hospital with a fracture in the left hip. The incident was documented as an unwitnessed fall, and the administrator considered it an explainable injury. However, there was no evidence that the injury, which met the criteria for an "injury of unknown source" per state guidance, was investigated or reported as required. Both incidents demonstrate a lack of adherence to facility policy and state regulations regarding the investigation and reporting of abuse, neglect, and injuries of unknown source. The facility did not ensure that all allegations were thoroughly investigated, nor did it report the results to the administrator or appropriate authorities within the required timeframe.
Failure to Accurately Reflect Active Diagnoses in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the active diagnoses of two residents. For one resident, the MDS did not include a known diagnosis of post-traumatic stress disorder (PTSD), despite documentation in the resident's face sheet, care plan, and a progress note by a nurse practitioner confirming the diagnosis. The MDS nurse acknowledged uncertainty as to why the PTSD diagnosis was omitted and confirmed that all active diagnoses within the 7-day look-back period should be included in the MDS. The Director of Nursing (DON) was also unsure about the presence of a formal PTSD diagnosis but stated that if it existed, it should have been documented in the MDS. For another resident, the MDS assessment failed to reflect active diagnoses of depression and anxiety, even though the resident was prescribed and receiving anti-anxiety and antidepressant medications for these conditions. The care plan and order summary documented the use of medications such as Ativan, Buspar, and Citalopram for anxiety and depression. The MDS nurse stated she was responsible for ensuring the accuracy of MDS assessments and that diagnoses were added based on review of orders and medical records. The DON confirmed that psychiatric diagnoses related to psychotropic medication use should be included in the MDS. Facility policy required qualified health professionals to correctly document residents' medical, functional, and psychosocial problems.
Failure to Update and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all aspects of a resident's activities of daily living (ADL) self-care performance. Record review showed that the resident had severely impaired cognition and required varying levels of assistance for multiple ADLs, including eating, hygiene, dressing, mobility, and transfers. However, the care plan did not include a specific focus area or interventions for the resident's ADL self-care needs, such as how to assist with transfers, bed mobility, or eating. Staff interviews confirmed that the care plan lacked detailed instructions for these tasks, and staff relied on verbal communication or the Kardex for guidance, which sometimes led to inconsistencies in care. The absence of updated and detailed care plan interventions for the resident's ADL needs was acknowledged by the ADON, MDS nurse, and DON, who all indicated that the care plan should have included this information to guide staff in providing appropriate care. The facility's policy required that qualified staff be notified of their roles and responsibilities for carrying out care plan interventions, both initially and when changes occurred, but this was not followed in the case of this resident. As a result, the resident's care plan did not reflect their current needs as identified in the comprehensive assessment.
Incomplete Respiratory Assessment Prior to Inhaler Administration
Penalty
Summary
A deficiency occurred when a respiratory therapist (RT) failed to provide a complete respiratory assessment prior to administering a prescribed albuterol inhaler to a resident with interstitial pulmonary disease and congestive heart failure. The RT only auscultated the top left and right lobes of the resident's chest from the front, neglecting to assess the back or the remaining lobes. The resident's medical record indicated a moderate cognitive impairment and a history of cardiorespiratory conditions. The RT did not assess the resident for pain at the time of medication administration. During interviews, the RT acknowledged that the standard practice was to listen to all lung lobes and admitted to being trained to do so, but did not follow this protocol. A registered nurse confirmed that the expectation was to assess all lobes before administering respiratory medication. Review of facility policies revealed no specific guidance on respiratory assessment, and the competency checklist required auscultation of breath sounds as part of the assessment. The facility did not have a policy specifically addressing respiratory assessment.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies in clinical documentation. For one resident, the admission record, care plan, and Minimum Data Set (MDS) did not include any medical diagnoses, despite the presence of multiple medication orders that referenced specific conditions such as COPD, hypertension, and anxiety. Hospital discharge records for this resident listed several diagnoses, but these were not reflected in the facility's electronic health record or care planning documents. The MDS nurse confirmed that diagnoses should be added during the admissions process and that the MDS had not yet been completed for this resident. For another resident, the facility did not accurately document a significant skin issue. After the resident sustained a laceration to the forehead requiring staples, the weekly skin assessment completed three days later indicated no new skin issues and did not mention the presence of staples or the wound. The medication administration record did include an order to monitor the laceration and staples, but this was not reflected in the skin assessment documentation. The DON stated that her expectation was for skin assessments to be completed accurately and for diagnoses to be present in every medical record upon admission.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically personal hygiene and bathing, for a resident with severe cognitive impairment. The resident, who was admitted with a BIMS score of 0 indicating severe cognitive impairment, required partial to moderate assistance with bathing and transfers. Despite this need, records showed that the resident received only one shower from admission until the date of the survey, and there were no care plan interventions or focus areas addressing ADLs or showers. The resident's name was not included on the shower schedule posted in the shower room, and staff interviews confirmed that the resident was not listed for showers and had not been showered since admission. Further, the resident was observed with greasy hair, and staff could not confirm whether the resident had been bathed as required. The facility's policy stated that residents should receive showers according to their preferences, care plan, and scheduled protocol, but this was not followed for the resident in question. The DON acknowledged that residents were expected to receive showers at least three times a week unless refused, but could not provide additional shower records for the resident. This lack of care and documentation resulted in the resident not receiving adequate personal hygiene services.
Failure to Provide Prescribed Snacks and Inadequate Snack Distribution Process
Penalty
Summary
The facility failed to ensure that residents received suitable and nourishing meals and snacks outside of scheduled meal service times, as required by their physician orders and care plans. Specifically, three residents with significant medical conditions, including muscle wasting, diabetes, malnutrition, and dysphagia, were not consistently offered or provided with prescribed snacks at bedtime or as otherwise ordered. Documentation on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was incomplete or missing for these prescribed snacks, and there was no evidence that the required snacks were consistently provided. Observations and interviews revealed that the process for distributing snacks was disorganized and inconsistent. Kitchen staff prepared snacks and left them at the nurse's station, often without labeling them with residents' names, except for those with specific physician orders. Staff interviews indicated that snacks were sometimes taken by residents from other units, and that agency staff or new staff were not always aware of residents' preferences or locations, resulting in missed snacks. There was confusion among staff regarding responsibility for snack distribution and documentation, with some believing it was the responsibility of CNAs, while others thought nurses or medication aides should be involved. Further, there was no set menu for snacks, and the dietary manager and registered dietician had not established clear procedures or oversight for snack provision. The dietary manager reported a lack of control over snack distribution after they left the kitchen, and the registered dietician was unaware of the issues. The facility did not provide a snack policy when requested, and staff interviews indicated that the labeling and tracking of snacks had become less consistent over time. These failures resulted in residents not receiving snacks as ordered, with some residents reporting they had not been offered snacks for an extended period.
Failure to Accurately Document Physician-Ordered Snacks and Supplements
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for three residents who had physician-ordered snacks and supplements. For one resident with muscle wasting, diabetes, and failure to thrive, the physician's order for a high protein snack at bedtime was not documented on the Treatment Administration Record (TAR), and there was no evidence the snack was being provided. The resident reported not being offered snacks for a long time, and the dietary profile and care plan indicated the need for a high protein snack due to his medical conditions. Another resident with protein-calorie malnutrition, muscle weakness, and feeding difficulties had a physician's order for health shakes at bedtime, but this order was not included on the MAR/TAR, and there was no documentation that the shakes were being provided. The resident's care plan and dietary profile reflected the need for supplements due to decreased intake and unplanned weight loss, but the required documentation and administration were missing. A third resident with dysphagia, muscle weakness, and anemia had orders for a mechanical soft diet, health shakes with snacks three times daily, and nightly snacks with documentation of acceptance or refusal. While the nightly snack was partially documented, the health shake order was not present on the MAR/TAR. The resident reported inconsistencies in receiving snacks, especially when agency staff were present. Interviews with staff revealed confusion about documentation responsibilities and unfamiliarity with the electronic record system, leading to incomplete records and potential lapses in care.
Failure to Knock Before Entering Resident Room Compromises Dignity and Privacy
Penalty
Summary
A deficiency was identified when a medication aide entered a resident's room without knocking, interrupting an interview between the resident and a state surveyor. The aide acknowledged forgetting to knock and stated that the resident's room was considered his home and that privacy was his right. The resident reported that staff often entered his room without knocking, which bothered him, especially when he had visitors or wanted privacy. He also noted that staff would not close the door behind them, which allowed other residents to wander into his room, and expressed that having his door closed was important to him. The resident involved was a male with a history of depression, muscle wasting, and activity limitations due to disability, and was assessed as moderately cognitively impaired. Interviews with facility leadership, including the interim DON and the administrator, confirmed that it was the facility's expectation for staff to knock before entering residents' rooms to respect their privacy and dignity. Review of facility policy also indicated residents' rights to privacy and dignity, including the right to private communication and a private environment.
Unsupervised Access to Disposable Razors in Memory Care Unit
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, poor safety awareness, and a history of physical aggression was found to have two disposable razors in his room. The resident required supervision with personal hygiene tasks, including shaving, and resided in a secure memory care unit due to impaired decision-making abilities. Observations on two consecutive days confirmed the presence of disposable razors on the resident's sink, and the resident reported shaving himself without staff assistance. Interviews with CNAs, an LVN, and the interim DON revealed that disposable razors were not permitted in resident rooms within the memory care unit due to safety concerns, as residents could harm themselves or others. Staff stated that razors should be kept in hygiene bags in the shower room and disposed of in a sharps container after use. Facility documentation also indicated that contaminated sharps, including razors, were to be handled only by designated staff and immediately discarded in designated containers. Despite these protocols, the resident had unsupervised access to razors in his room.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, specifically by hiring a Dietary Manager (DM) who did not possess the required certification, education, or qualifications for the position. The DM was hired with an associate degree in culinary arts and experience as a traveling chef in various healthcare settings but had not obtained Certified Dietary Manager (CDM) certification and had not enrolled in the required certification program. The Administrator acknowledged hiring the DM without confirming the necessary qualifications, and the Human Resources (HR) staff did not verify the DM's certification prior to hire, relying on the Administrator's decision. The HR staff also failed to follow up on obtaining the certification after the DM was hired, despite being told it would be provided. Interviews with facility staff confirmed that the DM had been in the role for approximately 2-3 weeks without the required certification, and the facility's dietician visited only twice a month to perform nutritional assessments. Review of the DM's job description and relevant federal food code regulations highlighted the requirement for a certified food protection manager, which was not met. The deficiency was identified for the only dietary staff reviewed, and the lack of appropriate qualifications could place residents at risk related to food safety and nutrition, as directly stated in the report.
Failure to Ensure Dietary Staff Hold Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies, skill sets, and accreditations in the food and nutrition service department, as evidenced by one dietary aide who did not possess a current and valid Texas Food Handler's Certificate. The dietary aide, who had worked in the facility for six months and was currently working as a cook, stated during an interview that he had not completed the required food handler's course due to lack of time. The aide also indicated that he was initially hired as a housekeeper and was moved to the kitchen because the facility was seeking staff to fill kitchen roles. The administrator confirmed that the aide had been informed multiple times about the need to obtain the certification but was unaware that it had not been completed until the time of the interview.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by accepted professional standards. For the first resident, the psychiatric provider's notes included diagnoses such as delusions, neuropathy, and dementia with behaviors, which were not reflected on the resident's face sheet or the facility's list of diagnoses. The resident had a history of Alzheimer's disease, cerebral infarction, and vascular dementia, with severe cognitive impairment and behavioral issues documented in the care plan. However, the additional diagnoses identified by the psychiatric provider were omitted from the official records. For the second resident, the psychiatric provider's notes listed Major Depressive Disorder as an active medical problem, and the resident was receiving amitriptyline for depression. Despite this, the diagnosis of Major Depressive Disorder was not included on the resident's face sheet or the facility's list of diagnoses. This resident also had severe cognitive impairment and was noted to have little or no activity involvement. During an interview, the DON confirmed that these omissions were likely due to a recent change in electronic health record providers and acknowledged that nursing staff and management were responsible for ensuring the accuracy of clinical records.
Unauthorized Access to Resident Records by Former Staff
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records, as evidenced by the unauthorized access and review of electronic medical records by LVN A. LVN A, who was no longer employed at the facility, accessed the medical records of three residents after being removed from the facility. This breach of privacy was discovered through a PHI audit log, which revealed that LVN A accessed various records, including face sheets and progress notes, for multiple residents. The incident came to light when an anonymous individual, who had received information from LVN A, contacted the responsible party of one of the residents shortly after the resident's death. This individual disclosed personal information and sent text messages containing sensitive details, which caused distress to the family. The facility's administrator was informed of the breach and initiated an investigation, which confirmed that LVN A had accessed the records after being designated as Do Not Return (DNR). Interviews with facility staff, including the Administrator, ADON, and DON, revealed a lack of a specific process for removing access to electronic medical records for staff who no longer worked at the facility. The ADONs were responsible for discontinuing access, but there was no assigned duty to ensure this was done promptly. The facility's policy on electronic medical records emphasized that only authorized persons should have access, but the lapse in deactivating LVN A's access led to the breach of confidentiality.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident with severe dementia, leading to a distressing situation for the resident's family. A visitor, not related to the resident, recorded and published a video on social media that depicted the resident in a manner that could be misinterpreted. The resident, who was severely cognitively impaired and unable to communicate effectively, was seen in the video interacting with the visitor in a way that was consistent with her baseline behavior due to dementia. The video was later removed from social media, but not before causing distress to the resident's family. The incident came to light when the resident's responsible party (RP) had an emotional outburst at the facility, upset by an anonymous call alleging that the video showed inappropriate behavior. The facility's Administrator had been aware of the video since it was first posted and had determined that no abuse had occurred, as the resident's actions were consistent with her known behavior. However, the Administrator had not informed the resident's family about the video, believing there was no need since no abuse was found. The facility did not have a policy prohibiting visitors from recording residents, which contributed to the incident. Interviews with facility staff revealed that the visitor was banned from the facility after the video was discovered. The Director of Nursing (DON) and other staff members were not initially aware of the video, and the facility lacked a formal policy regarding visitor recordings. The Administrator believed the anonymous call was a malicious attempt by a disgruntled former staff member. Despite the facility's actions to address the situation, the lack of a clear policy on visitor recordings and the failure to communicate with the resident's family contributed to the deficiency in maintaining the resident's dignity and privacy.
Improper Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as observed during a survey. The deficiency was identified when ground beef and frozen shelled eggs were found to be improperly thawed and stored at unsafe temperatures. Specifically, the ground beef was measured at 71 degrees Fahrenheit, which is within the danger zone for food temperatures, and the eggs were previously frozen and cracked, posing a risk for bacterial growth. These items were intended for use in preparing a meatloaf meal for residents. The issue arose due to malfunctioning refrigeration equipment. The facility's walk-in refrigerator had been non-functional for over a year and was being used to store pantry items instead. A second walk-in refrigerator also failed, leading staff to use a temporary break room refrigerator, which was not maintaining safe temperatures. The temporary refrigerator was found to be at 54 degrees Fahrenheit, and the ground beef inside was at 71 degrees Fahrenheit. Staff were observed defrosting food items at room temperature, which is against safe food handling practices. Interviews with staff revealed a lack of awareness and adherence to proper food safety protocols. The kitchen staff admitted to not maintaining temperature logs for the temporary refrigerator and were unaware of when the ground beef was placed inside. The facility's Food Service Supervisor (FSS) and Administrator decided to cater meals after the surveyor's intervention, acknowledging the risk of foodborne illnesses from the improperly stored and thawed food items. The facility's policy on food preparation and service, which prohibits thawing at room temperature and requires maintaining food temperatures outside the danger zone, was not followed, leading to the deficiency.
Removal Plan
- No contaminated foods were prepared or provided to any residents. Food was discarded immediately upon observation of incorrect temperature.
- Industrial refrigeration was ordered.
- A refrigeration truck was ordered for cold storage.
- Food truck delivered.
- The physician was notified of the alleged deficiency. There were no new orders obtained.
- [NAME] was educated and suspended pending investigation.
- Dietary Staff has been educated on food temperatures, preparation, and service for all residents.
- Dietary Staff will notify the Administrator immediately if an occurrence of incorrect temperatures or questions/issues regarding food service and will follow procedures.
- Procedures include checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service.
- Interventions set in place to include catered food for residents for 3 meals per day.
- Contact and notification for recommendations from RD E.
- RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted.
- Ad-Hoc QAPI meeting was held with the Medical Director, NHA, RDO and Marketing Director, LVN to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy.
- Administrator completed 1:1 in-service with Dietary Manager on Food Preparation and Service policy.
- Staff educated by administrator on Food Preparation and Service policy.
- Dietary manager in-serviced by Registered dietician [RD H]. RD also in-service dietary staff as well.
- Facility leadership will complete education with all staff on Food Preparation and Service, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences, keep residents safe.
- The training was initiated and will be completed. Staff will not be allowed to work until they receive training.
- The policy pertaining to Food Preparation and Services was reviewed by the NHA, Marketing Director, LVN, DON, RDO, and Medical Director.
- IDT, including Administrator, DON, Activity Director, Marketing Director, HR, BOM will meet daily after rounds Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any Kitchen refrigerators or temperatures were out of appropriate range.
- The findings will be immediately brought to the Administrator for further action, if necessary.
- Grievances will be reviewed during morning meetings with Administrator and IDT team members for any follow-up needed.
- All grievances will be entered into the Grievance Log by Administrator and investigation form will be filled out accordingly.
- Administrator will monitor kitchen daily by doing rounds during business days for any change in kitchen refrigerator temperatures she will monitor on weekend days for one month and then random audits will be provided thereafter.
- An audit sheet of rounding will be kept in a binder specified for follow up.
- Admin or designee will conduct audits for daily rounds for one month then periodically thereafter.
- Administrator will be notified by staff of any issues noted in the dietary department.
- Administrator will monitor refrigerator temperatures daily during business days and weekend manager will monitor on weekends for appropriate functioning and temperature utilizing a thermometer placed in refrigerator.
- RDO will provide physical oversight at facility weekly and then random reviews after.
- The RDO will provide oversight of the Administrator to ensure the items on the removal plan are reviewed and completed.
Facility Fails to Maintain Safe and Comfortable Environment in Wing III
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in Wing III, as evidenced by a malfunctioning air conditioning system and a damaged light fixture. Observations revealed that the thermostat in Wing III registered temperatures as high as 100 degrees Fahrenheit, with a portable AC unit failing to adequately cool the area. Despite the high temperatures, interviews with residents indicated they did not complain about the ambient temperature and felt comfortable. However, the ADM acknowledged the risk of overheating and dehydration due to the high temperatures, and the DON noted the need for additional hydration and staff rounding to mitigate these risks. Additionally, a light fixture in a resident's room had a plastic cover hanging precariously, posing a risk of falling and shattering. The ADM confirmed the potential danger of the light fixture and acknowledged that the air conditioning had been out since 06/11/2024. The facility's maintenance policy, revised in December 2009, requires maintaining the building in good repair and ensuring the heating and cooling systems are in working order. However, the record review showed no additional staff were scheduled to assist with ensuring resident comfort and hydration during this period.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of nursing services over a 91-day period, where it was found that there was no RN coverage on specific dates: 01/01/2024, 01/06/2024, 01/07/2024, 01/12/2024, 01/13/2024, 01/14/2024, and 03/17/2024. The facility's census on 06/11/2024 indicated there were 78 residents, highlighting the potential impact of this deficiency on a significant number of individuals. The facility's records, including a digitally shared calendar, were reviewed and showed discrepancies in RN coverage. The calendar, which was created by the Administrator on 06/12/2024, listed RN hours for the dates in question, but further investigation revealed that these entries were made after the fact, with no supporting evidence of actual RN presence. The Administrator claimed that RN coverage was provided by salaried employees who did not clock in or out, but no additional documentation or RN Coverage policy was provided to substantiate this claim.
Unsecured Exterior Door Poses Hazard
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards when an exterior door on the 300-hallway was found open without an alarm sounding. This door led to a back parking lot adjacent to a major river and a busy roadway, posing potential risks to residents. At the time of the incident, 29 residents resided on the 300-hallway, and the total census was 78. The door was observed open, unlatched, and not locked, with no alarm sounding, which could have exposed residents to various hazards. Interviews revealed that staff were unaware the door was open, and it was not typically used by staff, residents, or visitors. The Maintenance Director (MNT DIR) indicated the door should latch upon closure and have a 15-second delay for emergency egress. It was suggested that the door might have been left open when someone emptied the drain bins of portable air conditioning units. The Administrator (ADM) and Director of Nursing (DON) acknowledged the risks associated with the open door, including potential elopement or unauthorized entry. The facility's maintenance policy requires maintaining the building in a safe and operable manner, which was not adhered to in this instance.
Failure to Administer Metoprolol as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of metoprolol tartrate 25 mg. The resident, a female with dementia and hypertension, was not administered the prescribed medication on multiple occasions between June 3, 2024, and June 12, 2024. The medication was marked as unavailable by the medication aides (MA L and MA M) during these times, despite the Director of Nursing (DON) stating that metoprolol should have been available in the emergency kit. The resident's care plan required the administration of medications as ordered, and the failure to provide metoprolol could have impacted the resident's blood pressure management. Interviews revealed that the medication aides did not access the emergency kit for the medication, and there was a lack of communication regarding the unavailability of the medication. The Assistant Director of Nursing (ADON) was not informed about the medication being out of stock, and the medication aides did not document the resident's blood pressure in the medication administration record (MAR) as expected. The facility's policy required medications to be administered safely and timely, but this was not adhered to, leading to the deficiency. The pharmacy had delivered the medication on May 20, 2024, and again on June 12, 2024, indicating that the medication should have been available during the period in question.
Improper Garbage Disposal and Damaged Dumpster Plug
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed in the condition of three dumpsters. Specifically, the middle dumpster (#2) had a damaged drain plug, which allowed ants to enter. Additionally, there was garbage and debris, including paper items, a face mask, a gasoline can, and a discarded water sprayer, scattered around the vicinity of the dumpsters. This situation was noted during an observation conducted on the morning of June 11, 2024. Interviews with the facility's Administrator and Maintenance Supervisor revealed acknowledgment of the issues. The Administrator admitted that the plug for the second dumpster needed replacement and attributed the scattered garbage to a recent storm. The Maintenance Supervisor, responsible for maintaining the cleanliness of the dumpster area, confirmed the presence of garbage and the need for cleaning. He also acknowledged the necessity of a working plug for the middle dumpster to prevent pest and rodent access. The facility's policy on food-related garbage and refuse disposal, revised in October 2017, mandates that garbage be stored in a manner inaccessible to pests and that storage areas remain clean, although it does not specifically address dumpster plugs.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure that Resident #1 received adequate supervision and assistance devices to prevent accidents. Resident #1, a [AGE] year-old female with diagnoses including Parkinson's disease, dementia, and ataxic gait, was left unattended in her wheelchair by NA I. This resulted in Resident #1 falling forward and sustaining a large hematoma and laceration on her head. The resident was noted to have poor trunk control and a history of leaning forward in her wheelchair, which was documented in her care plan and nursing notes. On the day of the incident, NA I placed Resident #1 in her wheelchair and locked it but left her unattended to retrieve an item from the resident's room. During this brief period, Resident #1 fell forward out of her wheelchair and hit her head on the floor. The fall occurred approximately two minutes after NA I left the resident. Upon returning, NA I and other staff found Resident #1 on the floor with a head injury, and emergency services were called immediately. The resident was sent to the hospital, where a CT scan revealed a large left frontal scalp contusion/hematoma without a fracture. Interviews with staff and record reviews indicated that Resident #1 had a history of poor trunk control and required frequent repositioning. Despite this, the resident was left unattended, leading to the fall. The facility's policy on fall risk management was not adequately followed, as Resident #1's need for constant supervision and appropriate positioning was not met. This failure to provide adequate supervision and assistance devices placed Resident #1 at risk for accidents and potential harm.
Facility Failed to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Observations revealed that the kitchen was dirty and unsanitary, with grease, dirt, and debris under refrigerators and the ice chest. Additionally, food in the pantry was stored on the floor, and there were mice droppings near a wall adjacent to the pantry. The Food Service Supervisor (FSS) acknowledged the sanitation issues and stated that she had been addressing them since being hired three weeks prior. The facility had a cleaning schedule, but it was not detailed enough to ensure thorough cleaning, and a new, more detailed cleaning sheet was implemented on 3/13/24. The Maintenance Director confirmed that holes allowing vermin entry had been sealed, and the kitchen was scheduled for power washing to remove grease and dirt from the walls. Interviews with the Dietician and facility staff revealed that the kitchen had ongoing sanitation concerns, including visible dust on pot hangers, dirty ceiling tiles, and evidence of mice droppings in the dry goods storage area. The local health department's inspection report from 12/29/23 also noted these issues and recommended immediate cleaning and resolution. The facility's Sanitation policy, dated October 2008, required the food service area to be maintained in a clean and sanitary manner, which was not being adhered to at the time of the survey. The facility had ordered catered meals for residents while the kitchen was closed for cleaning and sanitation on 3/13/24 and 3/14/24.
Improper Garbage Disposal Due to Missing Dumpster Plugs
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 3 dumpsters, as observed by surveyors. Specifically, the drain plugs were missing from Dumpsters #1 and #2. This issue was identified during an observation on 3/13/24 at 11:30 AM with the Maintenance Director, who confirmed the missing plugs and acknowledged that he had not checked on the dumpster plugs since being hired three weeks prior. The facility's policy on Food-Related Garbage and Refuse Disposal, revised in October 2017, did not address the requirement for plugs. The Maintenance Director admitted that checking the plugs was not part of his checklist and that he was unaware of the missing plugs, despite it being his responsibility to ensure their presence. The observation noted that the dumpster lids were closed, the bottoms had no holes or metal rot, and there were no pests or vermin around the site at the time of inspection.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice and rats in the kitchen. Observations revealed dried mouse droppings near the pantry area, sticky mouse traps on the floor, and a live mouse trap in the ceiling. When the Maintenance Director removed a ceiling tile, five dried vermin droppings fell onto a kitchen countertop. Staff were observed cleaning the kitchen, and no fresh droppings were found in the food pantry or refrigerators. The facility had a history of mice sightings and trapping, with 20 mice trapped three weeks prior to the survey and six more trapped by the pest control company. Interviews with staff indicated that the issue had been ongoing for some time. The Maintenance Director, who was informed of the problem by the outgoing Maintenance Director, took measures such as setting traps, sealing holes, and contacting pest control. The Food Service Supervisor (FSS) and other dietary aides confirmed sightings of live rats and droppings in the kitchen. The FSS stated that food in the pantry had been taken off the floor and placed in sealed plastic containers. The facility's pest control company had been making regular visits to address the issue, and an Ad hoc QAPI meeting was held to discuss the problem. Record reviews showed that the facility had a pest control contract and that the pest control company had made several visits to address the issue. The Resident Council minutes for the months of January, February, and March 2024 revealed no complaints about pest control or vermin sightings in the kitchen, halls, or resident rooms. The facility's in-service sheets on pest control training showed 100% staff participation. Despite these efforts, the presence of mice and rats in the kitchen indicated a failure to maintain an effective pest control program, potentially putting residents at risk of foodborne illnesses.
Failure to Coordinate PASARR Assessments and Submit NFSS Timely
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for Resident #1, who had diagnoses including Quadriplegic Cerebral Palsy, Schizophrenia, Severe Intellectual Disabilities, and Muscle Weakness. The resident's care plan indicated the need for specialized services such as rehabilitative therapy, behavioral support, and durable medical equipment. However, the facility did not submit the Nursing Facility Specialized Services (NFSS) request for therapy services in a timely manner, leading to a denial of the request. Specifically, the NFSS request was initially submitted with a typed signature instead of a unique and original signature, which was a requirement for approval. Despite being notified of the issue and instructed to resubmit with a valid signature, the facility failed to do so before the deadline, resulting in the denial of the specialized services for the resident. Interviews with the corporate nurse and the administrator confirmed that the MDS staff responsible for PASARR residents' care and treatment had been let go the previous week. Additionally, Therapist A admitted to initially typing his name on the NFSS request and later resigning with an original signature, although the exact date of this correction was unknown. The failure to submit the NFSS request correctly and timely could affect residents requiring PASARR services, potentially resulting in them not receiving the recommended specialized services. The facility's policy on admission criteria emphasized the need for coordination with the PASARR program, but this was not effectively implemented in this case.
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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