Avir At El Paso
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 7441 Paseo Del Norte, El Paso, Texas 79911
- CMS Provider Number
- 676431
- Inspections on file
- 39
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Avir At El Paso during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk of accidents for residents.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A resident with multiple chronic conditions experienced a G-tube dislodgement, after which nursing staff did not administer prescribed medications either via the tube or orally, despite the resident being on pleasure feedings. Staff did not contact the physician to clarify alternative medication routes and failed to inform the physician and family of the missed doses or the change in status. Facility leadership confirmed there was no documentation or communication regarding the inability to administer medications during this period.
A resident who had a G-tube reinserted required a stat KUB X-ray to confirm placement, but the imaging was not completed within the required timeframe. Nursing staff did not adequately document follow-up with the imaging provider or notify supervisory staff and the physician about the delay. The facility's contract required stat imaging within 60 minutes, but the exam was completed over eight hours later, and the facility's policy did not address stat orders.
Two residents with documented dysphagia did not have this diagnosis addressed in their care plans, despite requiring assistance with eating and having cognitive impairments. Staff interviews revealed that dysphagia was omitted from the care plans because it was considered a therapy diagnosis, even though facility policy requires all resident needs to be included in person-centered care plans.
The facility did not maintain a commercial dryer in the laundry department and failed to provide adequate hot water for showers and bathrooms in one hallway. Staff and residents reported delays in laundry services and the need to move residents to another hallway for showers due to insufficient water temperatures, with multiple temperature checks confirming water below the required range. The facility's policy on water temperature was reviewed, but no policy for essential equipment maintenance was provided.
Three residents were not treated with dignity when two had their names written in large letters on the front of their clothing, and another had an uncovered Foley catheter bag that was visible and touching the floor. Staff interviews confirmed that clothing should be labeled discreetly and that catheter bags should be covered, but these practices were not followed, leading to a failure to maintain resident privacy and dignity.
Several residents with significant medical and cognitive needs did not have access to their call lights, as observed during staff rounds. Call lights were found on the floor, behind beds, or otherwise out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed responsibility for ensuring call light access, but the deficiency persisted, impacting residents' ability to request assistance.
Three residents with significant cognitive or physical impairments did not receive appropriate foot care, as evidenced by observations of excessively long and thick toenails. Despite care plans and physician orders for podiatry services, there was a lack of documentation confirming that podiatrist visits occurred, and staff interviews revealed gaps in awareness and documentation practices. Facility policy required proper foot care, but these standards were not met for the residents reviewed.
Surveyors found that kitchen staff failed to properly clean and seal food containers, including a tub of chocolate icing with dried drippings and an improperly closed gallon of red liquid. Staff interviews confirmed awareness of required cleaning and storage procedures, but these were not followed.
Surveyors found that the facility did not maintain proper infection control practices, as several residents with indwelling catheters had their Foley bags touching the floor or placed inappropriately, and a linen cart cover in the laundry room was torn, exposing clean linen. Staff interviews confirmed awareness of the correct procedures, but these were not consistently followed, and facility policies did not address all aspects of catheter care.
A liquid medication bottle in a medication cart was found with dried debris on its opening, indicating a failure to maintain proper labeling and cleanliness as required by facility policy. Interviews with the ADON, LVN, and DON confirmed that staff are responsible for monitoring and auditing medication carts, but there was uncertainty about audit frequency. This issue affected the medication cart serving 26 residents in 100 Hall.
The facility did not properly dispose of garbage and refuse, as the dumpster was observed open with trash and food on the ground and food substances running down its side. Staff interviews confirmed knowledge of proper procedures, but the area was not maintained according to policy, which requires dumpsters to be covered and the surrounding area kept clean.
A resident in an LTC facility experienced a choking incident, but the LVN failed to conduct a thorough assessment or call 911 despite the family's request. The resident was later found in respiratory distress by another CNA, who advised the family to call 911. EMS found the resident unresponsive, and she was taken to the hospital where she was intubated and later expired. The facility's policy on airway obstruction management lacked specific assessment guidelines.
A resident with a history of respiratory issues experienced a change in condition, showing signs of distress such as blue lips and difficulty breathing. A CNA observed these symptoms but did not report them to the LVN, who also failed to reassess the resident or take emergency actions when informed by the family. The resident was later found unresponsive by EMS and was transferred to the hospital, where she was intubated and subsequently passed away.
The facility failed to accurately reflect oxygen therapy in the MDS assessments for three residents. One resident with COPD was observed using a nasal cannula, but her MDS did not reflect this therapy. Another resident with chronic hypoxia had orders for oxygen therapy, yet it was not coded in the MDS. A third resident with Alzheimer's had orders for oxygen as needed, but her MDS also lacked this coding. Observations showed all three residents with empty oxygen tanks, though they did not exhibit respiratory distress. MDS Coordinators acknowledged the responsibility for accurate coding, which impacts reimbursement.
The facility failed to implement comprehensive care plans for two residents requiring oxygen therapy. One resident with severe cognitive impairment and another with intact cognition, both with medical histories necessitating oxygen therapy, did not have their needs addressed in their care plans. Observations revealed an empty oxygen tank for one resident, and the MDS Coordinators admitted the oversight, highlighting the risk of not providing necessary treatment.
A facility failed to provide adequate respiratory care for residents requiring oxygen therapy, with several found with empty oxygen tanks and lacking proper signage outside their rooms. This deficiency posed a risk of oxygen desaturation and potential hazards like fire. Additionally, discrepancies in documentation and orders for oxygen therapy were noted, compromising resident safety.
The facility failed to properly store nasal cannulas for three residents and in one room, risking contamination. Observations showed cannulas hanging from wheelchairs or in the shower area without being bagged. Staff interviews confirmed the need for bagging to prevent contamination, but this practice was not consistently followed, indicating a lapse in the facility's infection control program.
A resident with a history of falls experienced a fall while attempting to turn off the TV without assistance. The incident was not immediately communicated to the family or physician, with the family learning of the fall the next day and the physician two days later. The LVN on duty, overwhelmed by a double shift, failed to notify the necessary parties, leading to a grievance by the family.
A facility failed to coordinate PASRR assessments for a resident with cerebral palsy, dementia, and a genetic disorder, leading to a delay in identifying the resident as PASRR positive. The Local Authority was not notified until months after admission, despite attempts by the resident's guardian to address the issue. The oversight was attributed to errors by hospital staff and a lack of follow-up by the former MDS nurse, compounded by the departure of the facility's MDS nurses.
A facility failed to create a comprehensive care plan for a resident with [NAME]-[NAME] syndrome, a genetic disorder. The resident, with severe cognitive impairment and multiple diagnoses, did not have a care plan addressing their specific needs. The DON acknowledged the oversight, noting the absence of specialized services or rehabilitation as recommended by PASRR. The facility's policy requires comprehensive care plans with measurable objectives, which was not followed.
A resident with a history of falls and high fall risk was not provided with a low bed or fall mat, leading to a fall where she sustained a skin tear and a wrist fracture. The facility failed to adhere to the care plan and lacked physician orders for safety measures, contributing to the incident.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with a history of falls and cognitive impairment, often resorted to banging on the wall for help, while another resident, also cognitively impaired, primarily yelled for assistance. Observations and interviews confirmed the call lights were not consistently accessible, highlighting a pattern of neglect in maintaining call light accessibility.
The facility failed to provide requested medical records to two residents or their legal representatives, violating their rights to access their own medical information. One resident's legal representative made multiple requests for complete medical records, which were not fulfilled due to administrative oversight. Another resident's family member requested an EKG report, but the request was not documented or communicated, resulting in the report not being provided.
The facility failed to notify the physician when two residents did not receive their prescribed IV antibiotics due to unavailability. For one resident, 7 doses were missed, and for another, 8 doses were missed. The facility did not document notifying the physician, leading to delayed treatment. The facility's policy requires prompt notification of changes, but this was not followed, resulting in a deficiency.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS did not reflect an Enteral Feeding tube, despite documentation in the care plan and medication records. Another resident's MDS did not document a right knee infection, despite medical records indicating treatment for septic arthritis and ongoing antibiotic therapy. The facility's policy did not address MDS accuracy, contributing to these errors.
The facility failed to coordinate necessary PASRR services for two residents with mental disorders and intellectual disabilities. One resident, with schizophrenia and bipolar disorder, did not receive agreed specialized services due to Medicaid authorization issues. Another resident, with dementia and Down syndrome, also lacked full coordination of recommended services. The facility did not provide a policy on PASRR coordination when requested.
A resident with a history of dementia and other medical conditions fell, resulting in a skin tear and wrist fracture. The facility failed to update the resident's care plan to address these injuries, as confirmed by staff interviews. The MDS nurse, who was new and in training, acknowledged the oversight. This deficiency could risk residents not receiving necessary care tailored to their needs.
A resident was observed using oxygen therapy without a physician's order, and the facility failed to document this in the resident's records, including the Physician Order Summary Report and Care Plan. The DON confirmed the oversight, citing staffing issues with MDS nurses as a contributing factor.
The facility failed to provide pharmaceutical services for two residents, resulting in missed doses of prescribed IV antibiotics. One resident did not receive Clindamycin for a UTI due to unavailability, and the facility did not notify the physician. Another resident missed Vancomycin doses due to lab result delays and pharmacy delivery issues, with no documentation of physician notification.
A resident at the facility did not receive timely laboratory services, resulting in delayed administration of IV antibiotics. The facility's lab provider failed to send test results on time, impacting medication delivery. Staff did not document notifying the physician of these delays, and a grievance was filed by the resident due to inconsistent antibiotic administration. The facility was in the process of changing lab providers.
A LTC facility failed to maintain complete and accurate medical records for two residents, leading to potential risks in their care. One resident's records lacked documentation of a fall, injuries, and pain management, while another resident's records did not document a change in condition or the administration of an IV antibiotic. Staff acknowledged the documentation failures, despite having been trained to follow procedures.
A resident did not receive 8 doses of prescribed IV antibiotics due to lab result delays and medication availability issues. The facility's grievance process was ineffective, as the Administrator was unaware of the grievance, and the physician was not notified of missed doses. This led to a failure in administering necessary medical treatment.
A resident in an LTC facility was subjected to the use of grab bars on their bed without a medical necessity or proper documentation, leading to a fall and injury. The facility failed to obtain a physician's order, conduct a comprehensive assessment, or secure consent for the use of grab bars, which were used as restraints. This oversight resulted in the resident sustaining a left wrist fracture and a contusion to the right hip after becoming entrapped between the mattress and the grab bar.
The facility did not conduct a criminal background check for the Administrator before he began his duties, as required by their policy. This oversight was discovered during an interview and record review, revealing no documentation of the necessary checks in the Administrator's personnel file. The facility's policy mandates such screenings to prevent abuse, neglect, and exploitation, but this was not adhered to, potentially placing residents at risk.
A resident with a history of falls and cognitive impairment fell from her bed due to improper use of a bed rail, which was installed without a complete risk assessment or informed consent. The facility did not have a physician's order for the bed rail, and staff interviews indicated the resident required close supervision. The facility's policy on bed rail use was not followed, leading to increased risk of injury.
The facility failed to provide physician-ordered wound care to six residents on multiple occasions, leading to increased risk of wound deterioration and infection. Interviews revealed that wound care was often missed on weekends, and there was no system in place to track whether care was being provided.
The facility failed to secure one medication cart and four treatment carts, leaving them unlocked and unattended. These carts contained various medications and medical supplies, posing a risk to residents who could potentially access them unsupervised. Staff interviews confirmed that the carts should have been locked to prevent unauthorized access, in accordance with the facility's medication storage policy.
The facility failed to ensure complete and accurate documentation of bathing assistance for four residents due to incorrect setup of CNAs' software at admission/readmission. This issue, identified through observation, interview, and record review, put residents at risk of diminished self-image, poor self-hygiene, and impaired skin integrity.
The facility, licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since February 2024. The current occupant of the social work office was a Social Work Trainee who was not licensed. The HR Manager and Administrator acknowledged the absence of a full-time social worker and the potential impact on residents' psychosocial and discharge planning needs, despite other staff members attempting to cover these duties.
A facility failed to develop a baseline care plan within 48 hours for a resident with significant medical needs, including diabetes, hypertension, and paraplegia. The delay in care planning led to the resident's care needs potentially being unmet, and the resident expressed concerns about the lack of a care plan and discharge planning.
A facility failed to implement an effective discharge planning process for a resident with diabetes, hypertension, and paraplegia, leading to increased risks for unmet care needs post-discharge. Despite the resident's clear goal of being discharged to the community, the facility did not develop a discharge plan until the day before discharge, and no referrals were made to local agencies as required by the facility's policy.
The facility failed to maintain an infection prevention and control program, resulting in two residents' catheter tubing and drainage bags being observed on the floor. Both a CNA and the DON acknowledged that the catheter tubing and drainage bags should not be on the floor due to infection control issues.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and nursing needs. Critical issues such as medication management, restlessness, hematomas, UTIs, and pneumonia were not adequately addressed, potentially compromising the residents' well-being.
The facility failed to conduct neurological checks for three residents after incidents that could have resulted in head injuries. One resident was found with a hematoma, another with a large bruise on the forehead and eye orbits, and a third on the floor with an abrasion to the chest. Despite the visible injuries and high risk of falls, the staff did not follow the facility's policy for unwitnessed falls or suspected head injuries.
A resident with a history of multiple health issues was found in a compromised position by the night nurse, who failed to assess for injuries or notify the physician. The next day, the resident was found with a hematoma and sent to the emergency department. The facility's policy on notification of changes in condition was not followed, leading to a delay in medical treatment.
The facility failed to implement written policies prohibiting abuse, neglect, and exploitation of residents and did not investigate or report two incidents where residents were found with hematomas of unknown origin. The incidents were not reported to the state office, and no investigations were conducted, despite the facility's policies requiring such actions.
The facility failed to report injuries of unknown origin involving two residents to the state agency as required. One resident was found with a hematoma on her forehead, and another resident was found with a large bruise on her forehead and bilateral eye orbits. Both incidents were not reported despite significant injuries and cognitive impairments.
The facility failed to implement policies to prevent abuse and neglect, resulting in two residents with injuries of unknown origin that were not thoroughly investigated or reported to the state office. One resident was found with a hematoma on her forehead, and another with a large bruise on her forehead and bilateral eye orbits. Both incidents were not properly investigated or reported as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Safe Environment and 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 did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Notify Physician and Family of Change in Resident Status and Missed Medication Administration
Penalty
Summary
The facility failed to immediately inform the resident, the resident's physician, and a family member of a significant change in the resident's status following the dislodgement of a G-tube. The resident, an elderly female with multiple diagnoses including dementia, Alzheimer's disease, diabetes with neuropathy, and a history of heart and vascular conditions, experienced a G-tube dislodgement. Physician orders indicated the need for tube feeding and administration of medications such as Lasix and Plavix via the G-tube. On the day of the incident, the G-tube was replaced and a KUB X-ray was ordered to confirm placement, but medications were not administered during this period. Nursing staff, including LVN A and LVN B, did not administer medications either via the G-tube or orally, despite the resident being on pleasure feedings and potentially able to tolerate oral medications. LVN A reported that he was told to hold all medications based on the outgoing nurse's report, and did not attempt oral administration. LVN B also did not administer medications by mouth, citing the resident's swallowing difficulties and lack of physician clearance, but did not contact the physician to clarify if oral administration was permissible. The physician later stated that she expected to be notified if medications could not be administered and that oral administration was a common alternative, but she was not informed of any issues or missed doses. Facility leadership, including the ADON and DON, confirmed that there was no documentation or communication to the physician regarding the inability to administer medications or the need for alternative routes. The ADON stated that staff were expected to follow up with the physician in such cases, and the DON noted that medications were held, possibly due to concerns about family approval, but expected staff to follow physician orders and document accordingly. The failure to communicate and consult with the physician regarding medication administration during the period when the G-tube was unavailable constituted the deficiency.
Failure to Ensure Timely Stat Imaging After G-Tube Reinsertion
Penalty
Summary
The facility failed to ensure timely and appropriate laboratory services for a resident who required a stat KUB X-ray following the reinsertion of a gastrostomy tube. After the resident removed her G-tube, nursing staff replaced it and obtained a stat order for imaging to confirm placement. Although the order was placed early in the morning, the imaging was not completed until late afternoon, well beyond the expected timeframe outlined in the facility's contract with the imaging provider. The contract specified that stat exams should be performed within 60 minutes of the call, but the actual imaging was completed over eight hours after the order was placed. Interviews revealed that the nurse responsible for the resident's care attempted to follow up with the imaging provider but did not document these actions in the medical record or the 24-hour report. The nurse also could not recall if the delay was reported to supervisory staff. The physician was not notified of the delay, and stated that if she had been informed by mid-morning, she might have directed the resident to be sent to the hospital for more timely intervention. The imaging provider confirmed that no follow-up calls were received from the facility regarding the stat order, and that earlier time slots for the exam were unsuccessful. Facility leadership, including the ADON and DON, stated that staff were expected to follow up with the imaging provider and escalate delays to supervisors and the physician. However, there was no evidence that these steps were taken. Additionally, the facility's policy on test results did not address procedures for stat orders, contributing to the lack of clear guidance for staff in urgent situations.
Failure to Include Dysphagia in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of the residents' needs, specifically omitting the diagnosis of dysphagia for two residents. Both residents had documented diagnoses of dysphagia oropharyngeal phase upon admission, but their care plans did not reflect this condition. The Minimum Data Set (MDS) assessments for both residents indicated varying levels of cognitive impairment and the need for supervision or assistance with eating, but did not note any signs or symptoms of swallowing disorders. Despite this, the care plans were not updated to include interventions or objectives related to dysphagia. Interviews with the Director of Nursing (DON) confirmed that dysphagia should have been included in the care plans, as it was present in the residents' diagnoses. The MDS coordinator stated that dysphagia was considered a therapy diagnosis and therefore was not added to the care plan, rationalizing that the residents' therapeutic diets addressed the issue. However, facility policy requires that care plans include measurable objectives and timetables to meet all resident needs, derived from comprehensive assessments. The omission of dysphagia from the care plans was identified through interviews and record reviews.
Failure to Maintain Essential Equipment and Hot Water Supply
Penalty
Summary
The facility failed to maintain essential mechanical and patient care equipment in safe operating condition, specifically in the laundry department and in the provision of hot water for resident showers and bathrooms. Observations revealed that one commercial dryer in the laundry department was not operational for approximately three weeks. Interviews with the laundry aide and housekeeping manager confirmed that the breakdown was reported immediately, but the necessary part had not been ordered due to issues with company credit cards and the cost of the part. As a result, laundry staff had to prioritize linen washing and work night shifts to meet the demand, causing delays in returning residents' personal clothing. Additionally, the facility failed to ensure that residents in one hallway had access to hot water in their showers and bathrooms. The maintenance director acknowledged receiving complaints about cold water at the beginning of the year and confirmed that residents from the affected hallway were being taken to another hallway for showers where the water temperature was adequate. Multiple temperature checks in resident rooms showed water temperatures well below the required minimum of 100 degrees Fahrenheit, with readings ranging from 82 to 97 degrees Fahrenheit. The maintenance director confirmed that the water was not within the acceptable range for comfortable showers. Interviews with residents and staff further corroborated the issue, with reports of inconvenience and frustration due to the need to shower outside their rooms. The facility's policy on safe water temperatures was reviewed, but no policy regarding the maintenance of essential equipment was provided to the surveyors upon exit.
Failure to Maintain Resident Dignity and Privacy in Labeling and Catheter Care
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by several observations and interviews involving three residents. Two residents were found wearing clothing with their names written in large black marker across the chest, which was visible to others. Both residents expressed that they did not like having their names displayed in this manner, and staff interviews confirmed that facility practice was to label clothing on the inside, not in visible areas, to protect privacy and dignity. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged that visible labeling could violate residents' rights and dignity. Another resident with a Foley catheter was observed multiple times with the catheter bag uncovered and touching the floor. The resident was not aware that the bag should be covered with a privacy bag or that it should not touch the floor, and he expressed feeling ashamed at the thought of others seeing the contents, especially while he had a urinary tract infection with visible blood in the tubing and bag. The facility's own catheter care policy required privacy bags to be used at all times to maintain dignity and privacy, but this was not followed in practice. Record reviews for the involved residents showed histories of cognitive impairment, depression, and anxiety, with care plans emphasizing the importance of maintaining dignity, privacy, and a home-like environment. Despite these documented needs, the facility's actions did not align with their stated policies or the residents' care plans, resulting in a failure to promote or maintain the residents' dignity and quality of life.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences regarding call light accessibility for five out of eighteen residents. Observations revealed that multiple residents did not have their call lights within reach: one resident's call light was hanging behind and below the bed, another's was on the floor at the foot of the bed, and others had their call lights either on the floor or hanging out of reach. These findings were corroborated by interviews with residents, who reported frustration and difficulty obtaining assistance when their call lights were inaccessible. The affected residents had significant medical conditions, including cerebral infarction, unsteadiness, cognitive communication deficits, muscle weakness, dementia, paraplegia, depression, osteomyelitis, chronic heart failure, and respiratory failure. Their care plans specifically required that call lights be kept within reach and that staff encourage their use for assistance. Despite these documented needs and interventions, staff failed to ensure that call lights were accessible, as observed during multiple rounds. Interviews with nursing staff, the ADON, and the DON confirmed that all staff were responsible for ensuring call lights were within reach and that regular rounds were conducted to check on residents. Facility policy also required that call lights be accessible at all times. However, the observations and resident interviews demonstrated that this policy was not consistently followed, resulting in residents being unable to call for help when needed.
Failure to Provide Proper Foot Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate foot care for three residents who required assistance with activities of daily living (ADLs), including personal hygiene and foot care. Observations revealed that these residents had toenails approximately one inch longer than the nailbed, thick, and in some cases yellow, indicating a lack of regular foot care. Record reviews showed that these residents had significant cognitive or physical impairments, such as severe cognitive impairment, hemiplegia, paraplegia, and muscle atrophy, which necessitated substantial or maximal assistance for personal hygiene and foot care. Care plans for the affected residents included interventions for regular nail checks and trimming, and physician orders were in place for podiatrist evaluation and treatment as needed. However, documentation did not confirm that the podiatrist had seen all residents as ordered, and there was no evidence in progress notes for at least one resident. Staff interviews revealed a lack of awareness regarding podiatrist visits and an absence of a policy requiring documentation of podiatry services provided. The process for identifying and addressing foot care needs relied on staff recognition and communication, but gaps in documentation and follow-through were evident. Facility policy stated that residents should receive proper treatment and care to maintain good foot health, but the observed conditions and lack of documentation demonstrated a failure to meet these standards. Staff acknowledged the risks associated with long toenails, such as pain, injury, and infection, and recognized that maintaining groomed toenails is part of resident dignity. Despite this, the facility did not ensure that appropriate foot care was consistently provided or documented for the residents reviewed.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store and maintain food items in accordance with professional standards for food service safety. Specifically, a tub of chocolate icing was found in the walk-in refrigerator with dried drippings around the lid, and a gallon of red liquid was not properly closed. These issues were directly observed during a kitchen inspection. Interviews with the kitchen cook and the Dietary Manager confirmed that staff were trained to clean containers with a damp cloth and sanitizer after each use and to ensure all containers and gallons were properly closed. Both staff members acknowledged that it was the responsibility of all kitchen staff to maintain these standards. The facility did not provide a relevant policy to surveyors prior to their exit.
Failure to Maintain Infection Control: Catheter Bag Placement and Torn Linen Cart Covers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where indwelling catheter tubing and collection bags for three residents were observed touching the floor or placed inappropriately. One resident with chronic kidney disease and neuromuscular bladder dysfunction was found with her Foley bag hanging from the bed frame but touching the floor. She was aware of the risk and stated she would call staff for assistance. Another resident with end-stage renal disease and a history of urinary tract infection was observed with his Foley bag touching the floor and reported not having been educated about the infection risks. A third resident with generalized edema and a suprapubic catheter had his Foley bag placed flat on a fall mat beside his bed. Staff interviews confirmed that Foley bags should not touch the floor, and that improper placement could lead to infection and cross-contamination. Additionally, the facility failed to ensure that linen cart covers in the laundry room were free of tears. An observation revealed a linen cart cover with a tear exposing clean linen. Staff interviews indicated that the purpose of the cover was to protect clean linen from contamination, and that the torn cover had been in use for several months. Staff members acknowledged their responsibility to report and address such issues, but the tear had not been corrected, increasing the risk of cross-contamination. A review of facility policies showed that while the infection prevention and control program required clean linen to be delivered and stored on covered carts, the policy on catheter care did not specifically address the prevention of infection related to Foley bags touching the floor. The deficiencies were identified through observations, interviews, and record reviews, and were acknowledged by various staff members, including nursing and housekeeping personnel.
Medication Storage and Labeling Deficiency Due to Unclean Bottle
Penalty
Summary
A deficiency was identified when a liquid medication bottle in the medication cart for 100 Hall was observed to have red dried debris on its opening. This observation was made during a survey, and it was noted that the presence of dried drippings could obscure the medication label or potentially contaminate the medication. The facility's policy requires that all medications be stored according to manufacturer’s recommendations and in a manner that ensures proper sanitation. Interviews with the ADON, LVN, and DON revealed that medication aides and nurses are responsible for maintaining the cleanliness and monitoring of medication carts, with additional oversight and audits expected from the LVN, ADON, and DON. However, there was uncertainty regarding the frequency of these audits, and it was acknowledged by staff that medication bottles should be clean and free from debris to prevent infection control issues. The deficiency affected the medication cart used for 26 residents in 100 Hall.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations of the dumpster area. The dumpster was found open, with trash and food left on the ground outside and an orange, brown food substance dripping down the side. These conditions were directly observed during a facility visit. Staff interviews confirmed awareness of the proper procedures, including tying up trash bags and disposing of them in the dumpster, as well as the importance of keeping the dumpster closed and the surrounding area clean. Despite daily environmental rounds by the Maintenance Director, which include picking up trash around the building and checking the dumpster, the area was not maintained according to facility policy. The policy requires dumpsters to be kept covered when not being loaded and the surrounding area to be kept clean to minimize debris and pest attraction. Interviews with the ADON/infection control nurse, Maintenance Director, and facility administrator all acknowledged the risks associated with improper garbage disposal and confirmed that all staff are responsible for maintaining the dumpster area.
Failure to Provide Adequate Emergency Response for Resident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who was reviewed for care. The incident involved a resident who had stopped talking while eating and spit out a piece of meat. A CNA informed an LVN about the situation, but the LVN did not conduct a thorough assessment, as she did not have her stethoscope to check lung sounds. Despite the family's request to call 911, the LVN suggested that the family could call 911 themselves and did not reassess the resident or stay to observe her eating. The resident was later found by another CNA to be slouching in bed, turning blue around the lips, and struggling to breathe. This CNA repositioned the resident but did not notify the LVN, as she was informed that the LVN had already assessed the resident. The family member was advised by the CNA to call 911, which they did. EMS arrived and found the resident unresponsive with rapid breathing and wheezing, and she was taken to the hospital where she was intubated and later expired. Interviews with staff and the family member revealed that the LVN did not take immediate action to address the resident's condition, and the facility's policy on managing airway obstruction did not specify the type of assessment to conduct. The Director of Nursing stated that the LVN should have checked the resident's airway and used a stethoscope to listen to lung sounds. The physician also indicated that immediate action should have been taken if the resident was seen turning blue and having difficulty breathing.
Failure to Respond to Resident's Respiratory Distress
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, leading to a serious incident. A CNA observed the resident with blue lips and difficulty breathing but did not report this change in condition to the LVN. The LVN, upon being informed by the family that they were requesting 911 to be called, did not reassess the resident's condition or take appropriate emergency actions such as checking lung sounds or attempting the Heimlich maneuver. The family eventually called 911, and the resident was transferred to the hospital, where she was intubated and later expired. The resident was an elderly female with a history of muscle weakness and acute respiratory failure with hypoxia. She was on a regular diet with thin liquids and had no documented swallowing issues. On the day of the incident, the resident choked on a piece of meat but was able to spit it out. Despite this, the resident's condition deteriorated, and she was found unresponsive with rapid breathing by EMS. The hospital records indicated diagnoses of aspiration of food and respiratory failure, and the resident was sedated and intubated upon arrival. Interviews with staff revealed that there was a lack of communication and appropriate response to the resident's change in condition. The CNA who observed the resident's distress did not report it to the nurse, and the LVN did not perform a thorough assessment or take immediate action when informed by the family. The facility's policy on managing airway obstruction did not specify the type of assessment to conduct, contributing to the inadequate response. This failure placed residents at risk for not being assessed by nursing staff, with serious changes in condition going unrecognized and untreated.
Inaccurate MDS Assessments for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents regarding their oxygen therapy. Resident #5, an 89-year-old female with COPD and a history of tobacco smoking, was observed using a nasal cannula and oxygen concentrator, yet her MDS did not reflect oxygen therapy. Despite being coded for oxygen therapy in her baseline care plan, there were no orders for oxygen therapy in her records. Observations revealed her oxygen tank was empty, although she did not exhibit signs of respiratory distress. Resident #9, a male with COPD and chronic hypoxia respiratory failure, was also not coded for oxygen therapy in his MDS, despite having orders for oxygen at 2 liters per minute via nasal cannula. His care plan indicated a risk of respiratory issues, and observations showed him using a nasal cannula with an empty oxygen tank. He did not show signs of breathing difficulty during the observation. Resident #10, a female with Alzheimer's and diabetes, was similarly not coded for oxygen therapy in her MDS, although her orders included oxygen as needed for shortness of breath. Her care plan noted impaired gas exchange related to lung issues, yet no oxygen orders were present at the time. She was observed with an empty oxygen tank but did not display respiratory distress. Interviews with MDS Coordinators confirmed the responsibility for accurate MDS coding, noting that inaccuracies could affect reimbursement.
Failure to Implement Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, specifically regarding their oxygen therapy needs. Resident #4, a female with severe cognitive impairment and a history of dysarthria and weakness, was admitted and re-admitted to the facility earlier in the year. Despite being coded for oxygen therapy in her assessments, her care plan lacked any mention of this critical treatment. During an observation, it was noted that her oxygen tank was empty while she was in her wheelchair, raising concerns about whether she received the necessary oxygen therapy. Similarly, Resident #7, a female with intact cognition and a history of acute respiratory failure, pneumonia, and pulmonary embolism, also did not have her oxygen therapy needs addressed in her care plan. Although her medical orders specified oxygen therapy at 2 liters per minute, her care plan did not include this focus area. The MDS Coordinators acknowledged the oversight, noting that the absence of a care plan for oxygen therapy could lead to staff not providing the necessary treatment.
Inadequate Oxygen Management and Signage in LTC Facility
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents requiring oxygen therapy, as observed during a survey. Specifically, five residents were found with empty oxygen tanks behind their wheelchairs, indicating a lack of proper monitoring and maintenance of oxygen supply. These residents, diagnosed with conditions such as Alzheimer's, COPD, and respiratory failure, were at risk of receiving inadequate oxygen support. Despite some residents not showing immediate signs of distress, the empty tanks posed a significant risk of oxygen desaturation. Additionally, the facility did not have proper oxygen signage outside the rooms of residents on oxygen therapy. This lack of signage was observed in multiple rooms, which is a violation of the facility's own policy requiring oxygen warning signs to prevent potential hazards such as smoking near oxygen sources. The absence of these signs could lead to dangerous situations, including the risk of fire. Furthermore, there were discrepancies in the documentation and orders for oxygen therapy. For instance, one resident was using oxygen without any documented orders, while another resident's care plan did not include oxygen therapy despite being coded for it. These documentation issues highlight a lack of adherence to professional standards and the facility's policies, potentially compromising the safety and well-being of the residents.
Improper Storage of Nasal Cannulas in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper storage of nasal cannulas for three residents and in one room. Observations revealed that the nasal cannulas for Residents #3, #4, and #5 were not stored in zip lock bags or baggies, which is a necessary practice to prevent contamination. Instead, the cannulas were found hanging from wheelchairs or in the shower area, exposing them to potential contamination. Resident #3, diagnosed with Alzheimer's Dementia and respiratory failure, was observed with a nasal cannula hanging from a wheelchair without proper storage. Resident #4, with severe cognitive impairment and on continuous oxygen therapy, had a nasal cannula placed over a wheelchair shoulder, with footrests on top of the tubing, and lacked a care plan for oxygen therapy. Resident #5, diagnosed with COPD and respiratory failure, was seen with a nasal cannula not properly stored, despite being on oxygen therapy. Interviews with facility staff, including a physician, CNA, LVN, and the DON, confirmed that nasal cannulas should be bagged to prevent contamination. However, it was noted that this practice was not consistently followed, as cannulas were often hung on wheelchairs or other areas. The facility's Infection Prevention Control Program policy emphasizes maintaining a safe and sanitary environment to prevent infections, yet these observations indicate a lapse in adherence to the policy.
Failure to Notify Family and Physician of Resident's Fall
Penalty
Summary
The facility failed to immediately notify and consult with the resident's physician and the resident's representative when there was a significant change in the resident's condition. This deficiency involved a resident who experienced a fall on 09/24/24. The resident, who had a history of falls and was diagnosed with dementia and muscle weakness, was found on the floor mat after attempting to turn off the TV without assistance. Despite the fall, the resident was assessed to have no signs of injury, and neurological checks were within normal limits. The incident was not promptly communicated to the resident's family or physician. The family member, who was the resident's representative, was not informed of the fall until the following day, and the physician was notified two days later. This delay in communication was attributed to the LVN on duty, who was working a double shift and reported being overwhelmed and busy, leading to the oversight. The family member discovered the fall incident during a visit when the resident complained of pain, prompting an inquiry into the incident. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the facility's policy required immediate notification of the physician and family in such incidents. However, the LVN failed to adhere to this policy, resulting in a grievance filed by the family. The facility's documentation and interviews highlighted the lapse in communication and the subsequent investigation into the incident, which revealed the LVN's failure to notify the family promptly.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for a resident diagnosed with cerebral palsy, dementia, and a genetic disorder causing obesity, intellectual disability, and shortness in height. The resident was admitted to the facility with a PASRR Level 1 screening that did not indicate any mental illness, intellectual disability, or developmental disability, which was later identified as an error. The facility did not submit the PASRR information into the LTC Online Portal in a timely manner, leading to a delay in the resident being identified as PASRR positive. Interviews revealed that the Local Authority was not notified of the resident's PASRR status until months after admission, despite attempts by the resident's guardian to address the issue. The Local Authority representative discovered the lack of PASRR documentation and followed up with the facility, which eventually submitted the necessary information. The facility's MDS nurse acknowledged the oversight and attributed it to a previous error by hospital staff and a lack of follow-up by the former MDS nurse. The Director of Nursing (DON) confirmed that the facility's MDS nurses had left around the time of the resident's admission, contributing to the oversight. The resident received therapy services as a skilled nursing patient, but the failure to follow the PASRR process risked not capturing additional services and support available through PASRR. The facility's policy required coordination with the PASRR program to ensure appropriate care for residents with mental disorders or intellectual disabilities, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident with Genetic Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with a genetic disorder known as [NAME]-[NAME] syndrome. This deficiency was identified during a review of the resident's care plan, which lacked a specific focus or intervention plan addressing the syndrome. The resident, who was admitted with multiple diagnoses including cerebral palsy, dementia, and [NAME]-[NAME] syndrome, had a severe cognitive impairment as indicated by a BIMS score of 00. Despite being stable on current medication, the resident exhibited symptoms such as laughing hysterically during a psychiatric evaluation, which were not addressed in the care plan. The Director of Nursing (DON) acknowledged the omission, noting that the care plan should have included a focus on [NAME]-[NAME] syndrome. Additionally, the resident's PASRR assessment was initially incorrect and later redone, confirming a positive result for intellectual and developmental disabilities (IDD). However, the care plan did not incorporate any specialized services or rehabilitation services as recommended by PASRR. The facility's policy mandates the development of a comprehensive care plan with measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Inadequate Supervision and Accident Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention measures for a resident, leading to an incident where the resident fell from her bed. The resident, who had a history of falls and was identified as a high fall risk, was not provided with a low bed or a fall mat as per her care plan. This oversight resulted in the resident's left arm getting caught between the grab bars and the mattress, and her right shoulder and arm hitting a tray table and trash can, respectively, before she fell to the ground. The resident, who had a medical history including dementia, diabetes, and recurrent urinary tract infections, was found on the floor by staff after the fall. She sustained a skin tear on her left forearm and was later diagnosed with a left wrist fracture and a contusion on her right hip. The facility's records indicated that there were no physician orders for the use of grab bars, fall mats, or lowering the bed, despite these being part of the resident's care plan. Interviews with staff revealed that the resident was known to be impulsive and frequently attempted to toilet without assistance. The facility's failure to adhere to the care plan and ensure the resident's environment was free from accident hazards contributed to the incident. The lack of documentation and physician orders for the use of safety measures further highlighted the deficiency in the facility's supervision and accident prevention protocols.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within their reach, which compromised their ability to call for assistance when needed. Resident #1, who had a history of falls and cognitive impairment, was observed multiple times without the call light within reach. Despite being able to verbalize needs and use the call light, Resident #1 often resorted to banging on the wall to seek assistance, indicating that the call light was not consistently accessible. Interviews with staff and family members confirmed that the call light was not always placed within reach, and the resident's impulsive behavior and unsteady gait required close supervision. Resident #2, who also had cognitive impairments and required assistance with activities of daily living, was similarly found without the call light within reach. Observations revealed that the call light was often placed on a nightstand or attached to a pillow, making it inaccessible to the resident. Staff interviews indicated that Resident #2 occasionally used the call light but primarily yelled for assistance, further highlighting the inconsistency in ensuring the call light was accessible. The deficiency was identified through observations, interviews, and record reviews, which demonstrated a pattern of neglect in maintaining the call lights within reach for these residents. The facility's failure to adhere to its policy of ensuring call lights are accessible placed the residents at risk of not being able to call for help, as evidenced by the residents' alternative methods of seeking assistance and the staff's acknowledgment of the oversight.
Failure to Provide Medical Records to Residents
Penalty
Summary
The facility failed to provide requested medical records to two residents or their legal representatives, violating their rights to access their own medical information. For Resident #5, the legal representative made multiple requests for the resident's complete medical records, starting with a certified letter in July 2023, followed by several follow-up letters, emails, and phone calls. Despite these efforts, the facility did not provide the requested records. The Medical Records Clerk and the Assistant Business Office Manager were unaware of these requests, and the former Administrator did not process the request, leading to a significant delay in fulfilling the legal representative's request. Resident #5 had a history of chronic paraplegia, hypertension, and deep vein thrombosis, and was transferred to the facility for rehabilitation. The resident was cognitively intact and required extensive assistance with activities of daily living. The legal representative's request for records was related to determining guardianship, and despite the facility's policy on releasing medical records, the request was not fulfilled in a timely manner. The Medical Records Clerk eventually became aware of the request but was awaiting instructions from the corporate office. For Resident #2, a family member requested a copy of an EKG report after being informed of the results by an LVN. However, the LVN did not document the request or notify the DON or Medical Records Clerk, resulting in the family member not receiving the requested EKG report. Resident #2 had a complex medical history, including hypertension, dementia, and epilepsy, and required assistance with activities of daily living. The facility's failure to provide the requested medical records for both residents highlights a deficiency in adhering to state and federal laws regarding the release of medical records.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for two residents. For Resident #2, the facility did not have 7 doses of the prescribed IV antibiotics on hand to administer according to the physician's orders. Despite the medication being unavailable, there was no documentation that the attending physician or nurse practitioner was notified of this issue. The medication was not administered on multiple occasions, and it took three days for the nurses to report the issue to the physician and change the medication from IV to oral administration. Interviews revealed that the nurses were trained to notify the physician immediately if medications were not available, but this protocol was not followed. Resident #3 also experienced a failure in medication administration. The facility did not have 8 doses of the prescribed IV antibiotics on hand, and there was no documentation that the physician was notified of the medication not being administered as ordered. The resident's family expressed concerns about the inconsistency in providing antibiotics, and the facility's grievance report indicated that lab results were not received on time, delaying the administration of the IV antibiotic. The attending physician expected the licensed staff to report any issues with medication administration, but this was not done, leading to missed doses. The facility's policy on notification of changes requires prompt consultation with the resident's physician and notification of the resident's family when there is a change requiring such notification. However, in both cases, the facility failed to adhere to this policy, resulting in delayed medical treatment for the residents. The lack of documentation and timely communication with the physician contributed to the deficiency, as the facility did not ensure that the prescribed medications were administered as ordered.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. For one resident, the MDS did not reflect the presence of an Enteral Feeding tube, despite the resident having a PEG tube for enteral feeding as documented in the care plan and medication administration records. This oversight occurred after the departure of two MDS nurses, leaving the facility with newly hired, inexperienced staff who were still in training. The Director of Reimbursement completed the MDS assessment, which failed to document the resident's enteral feeding status. Another resident's MDS assessment did not document an infection in the right knee, despite medical records indicating treatment for septic arthritis and ongoing antibiotic therapy. The resident was admitted for rehabilitation and IV antibiotics following surgery for a right knee infection. The care plan and physician orders confirmed the presence of an infection and the need for antibiotics, yet this was not reflected in the MDS. The facility's policy on maintaining MDS assessments did not address accuracy, contributing to these documentation errors.
Failure to Coordinate PASRR Services for Residents
Penalty
Summary
The facility failed to coordinate with the appropriate state-designated authority to ensure that individuals with mental disorders, intellectual disabilities, or related conditions received the necessary care and services. This deficiency was identified for two residents who were reviewed for PASRR services. The facility did not provide the specialized services agreed upon during interdisciplinary meetings for these residents, which could potentially affect their health and well-being. Resident #4, a female with a history of schizophrenia, bipolar disorder, and other mental health conditions, was admitted to the facility for rehabilitation following a fracture. Despite being identified as PASRR positive for intellectual/developmental disability and severe mental illness, the facility did not coordinate the required specialized services. The resident's care plan included interventions such as inviting representatives from the LMHA to care plan meetings and coordinating services, but these were not adequately implemented. Additionally, there were issues with the processing of occupational therapy requests due to Medicaid authorization problems. Resident #6, a female with dementia and Down syndrome, also did not receive all the specialized services recommended for her PASRR positive status related to intellectual/developmental disability. Her care plan indicated the need for specialized services, including a customized manual wheelchair and therapy services, but these were not fully coordinated. Initially, the resident was not eligible for Medicaid, and the facility covered therapy costs, but later Medicaid services were obtained. However, the facility failed to provide a policy and procedure on PASRR and coordination of specialized services when requested by the surveyor.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who sustained a fall, resulting in a skin tear and a fracture to her left wrist. The deficiency was identified during a review of the resident's care plan, which did not address these injuries. The resident, who had a history of dementia, diabetes, recurrent UTIs, and other medical conditions, was admitted to the hospital following the fall for pain management and further evaluation of her injuries. The resident's medical records indicated that she was wheelchair-bound and required assistance with activities of daily living. Despite these needs, the care plan was not updated to reflect the resident's new injuries and the necessary interventions to address them. Interviews with facility staff, including the Director of Nursing and the MDS nurse, confirmed that the care plan had not been revised to include the skin tear and wrist fracture. The MDS nurse, who was new and in training, acknowledged that the changes should have been care planned but had not been completed. The facility's policy on comprehensive care plans, implemented in July 2022, requires the development of a person-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, this policy was not followed in the case of the resident who fell, leading to a deficiency in the care provided. The lack of an updated care plan could place residents at risk of not receiving the necessary care or services tailored to their individual needs.
Failure to Document Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who was on oxygen therapy without a physician's order. This deficiency was identified during an observation, interview, and record review process. The resident, who had a history of right hip fracture, diabetes mellitus type II, recurrent urinary tract infections, dementia, and hypertension, was observed using a portable oxygen cylinder attached to her wheelchair. However, there was no documentation of a physician's order for oxygen in the resident's records, including the Physician Order Summary Report and the Care Plan. Additionally, the Quarterly MDS assessment did not document that the resident was receiving oxygen. The Director of Nursing (DON) confirmed that the MDS assessment completed by the Director of Reimbursement failed to document the resident's oxygen use. The DON also revealed that the facility was experiencing staffing issues, as two MDS nurses had quit simultaneously, and new nurses were still in training. This lack of documentation and oversight could potentially place residents at risk of receiving incorrect or inadequate oxygen support.
Failure to Administer Prescribed IV Antibiotics
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in a deficiency. For Resident #2, the facility did not have the prescribed IV antibiotics on hand and failed to immediately consult with the physician or Nurse Practitioner. The resident was supposed to receive Clindamycin Phosphate intravenously three times a day for a UTI, but the medication was not available for several doses. There was no documentation that the attending physician or NP was notified about the unavailability of the medication, which led to a delay in medical treatment. Resident #3 also experienced a similar issue with the administration of IV antibiotics. The resident was admitted for IV antibiotics following surgery for right knee septic arthritis. The facility did not have the prescribed Vancomycin on hand for multiple doses, and there was a delay in receiving lab results necessary for determining the appropriate dosage. The facility failed to document that the physician was notified about the medication not being administered as ordered due to pending lab results and pharmacy delivery issues. The deficiency was further compounded by the facility's failure to document communication with the physician regarding the missed doses and the reasons for the delay. Both residents were at risk of delayed medical treatment due to the facility's inability to ensure timely administration of prescribed medications. The facility's policy on medication administration requires that medications be administered as ordered by the physician, but this was not adhered to in these cases.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who required IV antibiotics following a hospital discharge for right knee septic arthritis. The resident was admitted to the facility for physical therapy and rehabilitation, with a care plan that included administering antibiotics as ordered by the physician. However, the facility did not ensure that laboratory tests, specifically Vancomycin trough levels, were conducted and results received in a timely manner, which led to delays in administering the prescribed antibiotics. Interviews and record reviews revealed that the facility's lab provider did not consistently send test results on time, causing delays in the delivery of medication from the pharmacy. The attending physician expected the staff to notify them if medications were not administered as ordered due to lab issues, but there was no documentation that the physician was informed of these delays. The facility's staff, including the ADON and LVN, acknowledged the issues with the lab provider and the impact on medication administration. The deficiency was further highlighted by a grievance from the resident, who reported inconsistent administration of antibiotics. The facility's DON noted that the medication required lab results prior to every third dose, and the family was dissatisfied with the explanation provided. The facility was in the process of changing lab providers due to these ongoing issues, but no policy or procedure for laboratory services was provided to the surveyor before the exit.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks in their care. For one resident, the facility did not document a change in condition, specifically a fall, and failed to complete the SBAR INTERACT Communication Form, leaving blanks in the documentation. Additionally, the facility did not document injuries or mental status at the time of the incident, nor did it document an order for the use of grab bars. Pain evaluations were incomplete, with missing signatures and dates, and there was a lack of documentation regarding the administration of pain medication. For the second resident, the facility did not document a change in condition when an irregular pulse was noted, and there was a failure to notify the attending physician or document the notification in the resident's electronic record. The facility also failed to document that an IV antibiotic was not administered as ordered, and there was no record of notifying the physician about this issue. Furthermore, the administration of pain medication was not documented according to the physician's orders, and there was no documentation of the type of pain or follow-up on the effectiveness of the medication. These documentation failures could place residents at risk of not receiving needed services. The facility's staff, including LVNs and the ADON, acknowledged the lack of documentation and the failure to follow established procedures for documenting changes in condition and medication administration. Despite training, the staff did not consistently document in the residents' clinical records, leading to incomplete and inaccurate medical records.
Failure to Resolve Grievance on Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, specifically regarding the administration of IV antibiotics to Resident #3. The resident, who was admitted for IV antibiotic therapy following surgery for right knee septic arthritis, did not receive 8 doses of the prescribed medication due to issues with lab results and medication availability. The grievance filed by the resident's family highlighted inconsistencies in administering the antibiotics, which were not resolved promptly by the facility. The investigation revealed that the facility's grievance process was not effectively managed, as the designated Grievance Official, the Administrator, was on vacation and the covering Administrator was unaware of the grievance. The nursing staff, including LVN F and the ADON, reported delays in receiving lab results necessary for adjusting the Vancomycin dosage, which led to missed doses. Additionally, there were issues with the pharmacy not delivering the medication on time, further contributing to the failure to administer the antibiotics as ordered. Interviews with the attending physician and the social worker confirmed that the physician was not notified of the missed doses, which is a critical step in ensuring timely medical treatment. The facility's policy required immediate notification to the physician if medications were not administered as ordered, but this was not documented in the resident's electronic Nurse's Progress Notes. The lack of communication and documentation resulted in the resident not receiving the necessary medical treatment, as the facility did not follow its grievance policy and procedures effectively.
Inappropriate Use of Grab Bars as Restraints
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints, as evidenced by the use of grab bars on the resident's bed without a medical necessity or proper documentation. The resident, who had a history of falls and cognitive impairment, was using grab bars to assist with bed mobility and transfers. However, there was no physician's order for the use of these grab bars, nor was there a comprehensive assessment or signed consent from the resident's responsible party. This lack of documentation and assessment led to the inappropriate use of the grab bars as a restraint. The deficiency was further highlighted when the resident sustained a fall, resulting in a left wrist fracture and a contusion to the right hip. The incident occurred when the resident's left arm became entrapped between the mattress and the grab bar, causing a skin tear. The facility's policy on the use of bed rails was not followed, as there was no evidence of alternative approaches being attempted prior to the installation of the grab bars, nor was there an assessment of the resident's risk of entrapment. Interviews with staff revealed that the resident was impulsive and required close supervision, yet the facility did not have adequate measures in place to ensure the resident's safety without the use of restraints. The facility's failure to adhere to its own policies and procedures regarding the use of bed rails and restraints contributed to the resident's injury and compromised the resident's dignity and right to be free from unnecessary restraints.
Failure to Conduct Background Check for Administrator
Penalty
Summary
The facility failed to implement its written policies that prohibit and prevent abuse by not conducting a criminal background check for the Administrator before he began his duties. The Administrator started on 05/13/24, but during an interview and record review on 07/12/24, it was revealed that there was no documentation in his personnel file indicating that a Criminal Check, Employee Misconduct Check, and Nurse Aide Registry Check had been completed prior to or on his first day of work. The Administrator acknowledged this oversight and mentioned that he had terminated the HR manager on 07/11/24, who was responsible for these checks, and attempted to contact him to verify if the checks had been completed. The facility's Policy & Procedure, dated 07/20/22, mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes conducting background, reference, and credentials checks on potential employees, contracted temporary staff, students, volunteers, and consultants. The policy also requires maintaining documentation of proof that the screening occurred. The failure to conduct and document these checks for the Administrator could place residents at risk of potential abuse.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess a resident for the risk of entrapment from a bed rail, also known as an enabler, before its installation. The assessment form for the resident was incomplete, lacking signatures and responses to critical questions about the risks associated with using enablers. This oversight occurred despite the resident's history of falls and cognitive impairments, which necessitated careful consideration of safety measures. The resident, who had a history of falls and was severely cognitively impaired, experienced a fall from her bed, resulting in a skin tear and a suspected fracture. The incident occurred while the resident was using a bed rail to assist with mobility. The facility did not have a physician's order for the use of the bed rail, nor was there informed consent from the resident or her representative. Interviews with staff revealed that the resident was impulsive and required close supervision, yet the necessary precautions and documentation were not in place. The facility's policy required a comprehensive assessment and informed consent before using bed rails, but these procedures were not followed. The lack of proper assessment and documentation placed the resident at risk of injury from inappropriate use of enablers. The facility also failed to conduct regular checks and maintenance on the bed rails, further increasing the risk of harm to residents.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, six residents did not receive physician-ordered wound treatment on multiple occasions. For instance, Resident #1 did not receive wound care on six occasions, despite having a history of diabetes, hypertension, and paraplegia, and requiring wound care for surgical incisions and skin tears. The resident even filed a grievance stating that he had to clean his own wounds, which was resolved by speaking to staff and putting the resident on 2-hour checks. However, documentation showed that wound care was still not provided as ordered on several dates in April 2024. Resident #2, who had a history of high blood pressure, coronary artery disease, diabetes, and dementia, did not receive wound care on 16 occasions. The resident had a Stage II pressure ulcer and a DTI, and the physician's orders for daily and every-other-day treatments were not documented as provided on multiple dates in March and April 2024. Interviews with staff revealed that wound care was often missed on weekends when the wound care nurse was not available, and floor nurses were expected to provide care but did not always do so. Other residents, including Resident #3, Resident #4, Resident #5, and Resident #6, also did not receive their prescribed wound treatments on several occasions. These residents had various medical conditions, including pressure ulcers, skin tears, and surgical wounds, and required specific wound care treatments that were not documented as provided. Interviews with staff and the DON revealed that there was no system in place to track whether wound care was being provided, leading to missed treatments and increased risk of wound deterioration and infection. The facility's policy on wound treatment management emphasized the importance of providing evidence-based treatments in accordance with physician orders, but this was not consistently followed.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed with one medication cart and four treatment carts being left unlocked and unattended. Specifically, on 05/04/2024, the 300 hall treatment cart, the rotunda treatment cart, the 200 hall treatment cart, the 100 hall medication cart, and the 100 hall treatment cart were all found unlocked and unattended. These carts contained various medications, including insulin, acetaminophen, stool softeners, and wound care items, posing a risk to residents who could potentially access these medications unsupervised. During interviews, staff members, including an LVN, the Weekend Supervisor, the Wound Care Nurse, the DON, and the Administrator, confirmed that the carts should have been locked to prevent unauthorized access. The LVN and the Weekend Supervisor specifically noted that leaving the carts unlocked posed a threat to resident safety, as confused residents could potentially ingest medications or injure themselves with medical equipment. The Wound Care Nurse highlighted the presence of sharp objects and wound care creams in the carts, which could be harmful if accessed by residents. The facility's policy on medication storage, dated 07/2022, mandates that all drugs and biologicals be stored in locked compartments, such as medication carts, and that medications must be under the direct observation of the person administering them or locked in the storage cart. Despite this policy, the observed lapses in securing the medication and treatment carts indicate a failure to adhere to these guidelines, thereby compromising resident safety.
Failure to Document Bathing Assistance
Penalty
Summary
The facility failed to ensure that medical records for residents were complete and accurately documented, specifically regarding the provision of assistance with bathing. This issue affected four residents, who had no documentation showing that bathing assistance had been provided due to incorrect setup of the CNAs' software at admission/readmission. This failure was identified through observation, interview, and record review, revealing that the lack of documentation put residents at risk of diminished self-image, poor self-hygiene, and impaired skin integrity. Resident #1, who had a history of diabetes, hypertension, and paraplegia, reported that staff sometimes missed his baths. His Point of Care ADL Bathing Task sheet showed no responses for the 30-day look-back period. Similarly, Resident #3, who had moderate cognitive impairment and required substantial assistance with bathing, also had no documentation of bathing assistance for the same period. Resident #4, with severe cognitive impairment and multiple pressure wounds, and Resident #6, with severe cognitive impairment and a recent hip fracture, also had no documentation of bathing assistance. Interviews with CNAs and the DON revealed that the issue stemmed from the absence of an MDS nurse to input residents' bathing preferences into the point of care software, which prevented the appearance of the bathtub icon on the CNAs' documentation screens. As a result, CNAs were unable to document that they had provided bathing assistance. The DON acknowledged that without documentation, it was as if the baths had not occurred, posing risks to residents' dignity, infection control, quality of life, and skin integrity.
Failure to Employ Full-Time Qualified Social Worker
Penalty
Summary
The facility, licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since February 2024. This deficiency was identified through interviews and record reviews. The Assistant Director of Nursing (ADON) confirmed that the current occupant of the social work office was a Social Work Trainee who was not licensed and was still completing her Bachelor of Social Work degree. The trainee had been responsible for resident assessments at admission and discharge planning for about two months. The HR Manager revealed that the previous full-time licensed social worker had changed to PRN status on February 29, 2024, and efforts to hire a new full-time social worker were ongoing, with a new hire scheduled to start on May 15, 2024. The Director of Nursing (DON) and the Administrator both acknowledged the absence of a full-time social worker and the potential impact on residents' psychosocial and discharge planning needs, despite other staff members attempting to cover these duties and the availability of a PRN social worker by telephone. The facility's policy, dated July 2022, mandates that a facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is defined as someone with a bachelor's degree in social work or a related human services field and one year of supervised social work experience in a healthcare setting. The failure to comply with this policy was evident as the facility did not have a full-time qualified social worker since February 2024, putting residents at risk of not having their psychosocial or discharge planning needs adequately met. The Administrator admitted that in the absence of a full-time social worker, residents might not receive necessary support for family issues or discharge planning.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission. The resident, who had a history of diabetes, hypertension, and paraplegia, was admitted with a pressure wound on the sacral area and had undergone surgeries for his right knee and an infected pressure wound. Despite these significant medical needs, the baseline care plan was not completed until several days after admission. This delay in care planning could result in unmet care needs for the resident. The resident expressed concerns about the lack of a care plan and the delay in discharge planning. The resident had requested a copy of his care plan and a care plan meeting, but these were not provided in a timely manner. The facility's Director of Nursing and Administrator acknowledged that the absence of a baseline care plan could lead to missed care. The facility's policy required the development of a baseline care plan within 48 hours of admission, but this was not adhered to in this case.
Failure to Implement Effective Discharge Planning Process
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident, leading to increased risks for unmet care needs post-discharge. The resident, who had a history of diabetes, hypertension, and paraplegia, was admitted to the facility following surgeries for his right knee and an infected pressure wound. Despite the resident's clear goal of being discharged to the community, the facility did not develop a discharge plan until the day before his discharge, and no referrals were made to local agencies as required by the facility's policy. Interviews and record reviews revealed that the resident had been asking about discharge planning but received no substantial assistance. The Social Work Trainee admitted that she did not document her interactions with the resident regarding discharge planning and that the responsibility for discharge decisions lay with the rehabilitation director, DON, and physicians. The DON was unaware of the risk of not having a discharge plan in place, and the Administrator acknowledged that without a baseline care plan, staff would not know how to care for residents, including planning for discharge. The resident was eventually discharged, but the home health company reported that the facility had not been in touch with them on the day of discharge, despite the resident's communication with the company. The facility's policy stated that discharge planning should begin at admission and include identifying the resident's goals and needs, developing interventions, and making necessary referrals, none of which were adequately followed in this case.
Infection Control Deficiency: Catheter Tubing and Drainage Bags on Floor
Penalty
Summary
The facility failed to maintain an infection prevention and control program, resulting in two residents' catheter tubing and drainage bags being observed on the floor. Resident #4, who has a history of urinary tract infections, encephalopathy, hypertension, diabetes, and Parkinson's Disease, was found with his catheter tubing and drainage bag lying on the floor. This was observed on 05/04/2024, and both a CNA and an LVN acknowledged that the catheter tubing and drainage bag should not be on the floor due to infection control issues. The CNA admitted to forgetting to reposition the bag and tubing after emptying it earlier in the morning. Similarly, Resident #7, who has a history of UTIs and uses a urinary catheter, was observed on 05/06/2024 with her catheter tubing and drainage bag dragging on the floor while she was wheeling herself in a wheelchair. The DON confirmed that the catheter tubing and drainage bag should not be touching the floor due to infection control concerns. The facility's policy on catheter care, dated 07/2022, mandates appropriate catheter care to maintain residents' dignity and privacy, but no specific policy on infection control related to catheter positioning was provided upon request.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and nursing needs. For Resident #1, the care plan did not address critical issues such as antiplatelet medication, feeding tube, restlessness in bed, anti-anxiety medication, hematoma, UTI, and pneumonia. Despite having a history of diabetes, hypertension, atrial fibrillation, and anemia, the care plan lacked measurable objectives and time frames to meet these needs, potentially compromising the resident's well-being. Resident #2's care plan was also found lacking in several areas. The resident, who had a history of Alzheimer’s dementia, generalized anxiety, and major depressive disorder, did not have a care plan that addressed restlessness in bed, anti-anxiety medication, hematoma, risk for bruising due to aspirin use, UTI, and pneumonia. The resident had a significant incident involving a hematoma to the forehead, which was not adequately addressed in the care plan, raising concerns about the resident's safety and care. Similarly, Resident #4's care plan failed to address multiple critical issues, including restlessness in bed, anti-anxiety/anti-psychotic medication use, pneumonia, UTI, hematoma, risk for bruising due to aspirin use, suprapubic catheter, incontinence of bowel, rehabilitation services, and skin tear. The resident, who had a history of diabetes, hypertension, coronary artery disease, and dementia associated with alcoholism, was at risk of not receiving the necessary care due to the incomplete care plan. The facility's failure to develop comprehensive care plans for these residents could place them at risk of not receiving the necessary care or services to address their needs.
Failure to Conduct Neurological Checks After Incidents
Penalty
Summary
The facility failed to ensure that residents received neurological checks after incidents that could have resulted in head injuries. Resident #1 was found with a hematoma on the right side of her forehead, but neurological checks were not initiated. The resident was cognitively impaired and had a history of falls, and the incident was not documented properly by the night nurse. The resident was eventually sent to the emergency room for evaluation, where she was diagnosed with a head contusion, UTI, and pneumonia. The failure to conduct neurological checks was confirmed through interviews with staff and review of records, which showed that the licensed staff did not follow the facility's policy for unwitnessed falls or suspected head injuries. Resident #2 was found with a large bruise on her forehead and bilateral eye orbits, but no neurological checks were completed. The resident had a history of Alzheimer’s dementia, hypertension, and other medical conditions, and was under hospice care. The incident report indicated that the resident was agitated and aggressive, and was found with a hematoma after lunch. Despite the visible injuries, the staff did not initiate neurological checks, and the resident was later sent to the hospital for a CT scan, which confirmed a forehead scalp hematoma. Interviews with staff revealed that they were aware of the need to report changes in condition and initiate neurological checks but failed to do so in this case. Resident #4 was found on the floor with an abrasion to his chest and was unable to say if he had hit his head. The resident had a history of falls, diabetes, hypertension, and dementia associated with alcoholism. Despite the high risk of injury, no neurological checks were documented following the incident. The DON confirmed that the neurological assessment flow sheet for this resident could not be found. Interviews with staff indicated that the resident required total care and had a history of falls, but the necessary neurological evaluations were not conducted as per the facility's policy. This failure to perform neurological checks placed the residents at risk of changes in condition due to unmonitored head injuries.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to consult with the resident's physician when there was a significant change in the resident's physical status. Specifically, the physician was not notified that a resident was restless and found with her face on the air mattress pump at the foot of the bed. This failure put the resident at risk of delayed medical treatment. The resident, who had a history of diabetes mellitus type 2, hypertension, atrial fibrillation, and anemia, was cognitively impaired and dependent on staff for most activities of daily living. On the night of the incident, the resident was found by the night nurse in a compromised position but was not assessed for injuries, and the physician was not notified. The next day, the resident was found with a hematoma on her forehead and was sent to the emergency department for evaluation. Interviews with staff revealed that the night nurse did not document the incident or notify the physician, and there was a lack of communication between shifts regarding the resident's condition. The facility's policy on notification of changes in condition was not followed, leading to a delay in medical treatment for the resident.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement written policies that prohibit abuse, neglect, and exploitation of residents and to investigate any such allegations for two residents. Specifically, the facility did not follow its policy on reporting allegations of all alleged violations to the Administrator, state agency, and other officials in accordance with state law. This failure was evident in two separate incidents where residents were found with hematomas of unknown origin, and no immediate investigation or reporting was conducted as required by the facility's policies. In the first incident, a resident with a history of cognitive impairment and multiple health issues was found with a hematoma on the right side of the forehead. The night nurse reported finding the resident in an unusual position in bed but did not assess for injuries or document the incident. The following day, another nurse noticed the hematoma and reported it to the Director of Nursing (DON), who then sent the resident to the emergency room. Despite the severity of the injury, the incident was not reported to the state office, and no investigation was conducted to determine the cause of the injury. In the second incident, another resident with severe cognitive impairment and a history of aggressive behavior was found with a large bruise on the forehead and around the eyes. The staff reported that the resident had been agitated and forcefully opening and closing drawers and closet doors. However, no one witnessed the injury, and the source of the injury was unknown. The incident was not reported to the state office, and no investigation was conducted. The DON and Administrator later acknowledged that the incidents should have been reported and investigated according to the facility's policies and state regulations.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator and the State Survey Agency. This failure was observed in two residents who had injuries of unknown origin. Specifically, Resident #1 was found with a hematoma on the right side of her forehead, and Resident #2 was found with a hematoma on her forehead and bilateral eye orbits. Both incidents were not reported to the state agency as required by state law and facility policy. Resident #1, who had a history of diabetes mellitus type 2, hypertension, atrial fibrillation, and anemia, was found with a hematoma on her forehead on 04/17/24. The resident was cognitively impaired and dependent on staff for all activities of daily living. Despite the significant swelling and altered mental status, the incident was not reported to the state agency. Interviews with staff revealed that the night nurse had found the resident with her head against a metal hook at the foot of the bed but did not assess for injuries or document the incident. The Director of Nursing (DON) and the Administrator did not consider the injury reportable based on the night nurse's account. Resident #2, who had a history of Alzheimer’s dementia, generalized anxiety, and major depressive disorder, was found with a large bruise on her forehead and bilateral eye orbits on 04/05/24. The resident was under hospice care for terminal chronic obstructive pulmonary disease (COPD) and was severely cognitively impaired. The staff reported that the resident had been agitated and was forcefully opening and closing closet doors and dresser drawers. Despite the significant bruising and the resident's inability to explain the injury, the incident was not reported to the state agency. The DON and the Administrator did not classify the injury as reportable, although the facility's policy and state regulations required such incidents to be reported immediately.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for two residents reviewed for abuse and injuries of unknown origin. The facility did not ensure that the injuries of unknown origin for these residents were thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Resident #1, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found with a hematoma on the right side of her forehead. The injury was discovered by a nurse during a routine check, and the resident was subsequently sent to the emergency department for evaluation. The night nurse had previously found the resident in an unusual position in bed but did not assess or document any injuries at that time. The incident was not reported to the state office as required, and no thorough investigation was conducted to determine the cause of the injury. Resident #2, who had a history of Alzheimer’s dementia and was under hospice care, was found with a large bruise on her forehead and bilateral eye orbits. The staff reported that the resident had hit herself with a closing door, but there were no witnesses to the incident. The injury was not reported to the state office, and no thorough investigation was conducted. The facility's Director of Nursing and Administrator acknowledged that the incidents should have been reported and investigated according to the facility's policies and state regulations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
