Avir At Kerrville
Inspection history, citations, penalties and survey trends for this long-term care facility in Kerrville, Texas.
- Location
- 1555 Bandera Hwy, Kerrville, Texas 78028
- CMS Provider Number
- 745050
- Inspections on file
- 18
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Avir At Kerrville during CMS and state inspections, most recent first.
The facility did not employ a qualified full-time social worker despite having more than 120 beds, leaving the position vacant for several months after the prior social worker resigned. Review of the staff roster showed no social worker, and HR confirmed there was no full- or part-time social worker during that period. An RN acting as interim ADON reported attending care plan meetings without anyone assigned to perform social work duties. A part-time LSW later stated that before his start, no one was maintaining social work responsibilities and that he was addressing uncompleted reports and residents’ discharge needs once he began.
A resident with chronic pain and drug-induced polyneuropathy had active orders and a care plan for both scheduled and PRN analgesics, including pregabalin, tramadol, acetaminophen, and methocarbamol, and reported taking scheduled neuropathic pain medications with additional PRN doses several times per week. However, the quarterly MDS assessment documented that the resident had not received a scheduled pain regimen and had not received or been offered PRN pain medications in the look-back period. The MDS nurse, who was usually responsible for MDS completion but had been on leave and did not complete this assessment, later reviewed the section on pain management and acknowledged that the information recorded there was inaccurate.
The facility failed to maintain complete and accurate clinical records for multiple residents. A resident with a right thigh lymphatic ulcer had numerous ordered wound care treatments with no documentation on the TAR and no corresponding progress notes, and the diagnoses of lymphatic ulcer and lymphedema were not added to the diagnosis list despite repeated documentation in wound and MD notes. Another resident with a PEG tube and severe malnutrition had several scheduled enteral feedings with either blank MAR entries or exemption codes without supporting progress notes. A third resident receiving IV imipenem-cilastatin for a UTI had multiple scheduled IV doses with missing documentation and no progress notes to verify administration. A fourth resident with COPD and malnutrition had weekly and one-time ordered weights that were not documented on required dates, despite care plan and MD orders to monitor and evaluate weight.
A resident with a documented right thigh wound and MRSA infection had an active wound care plan, multiple wound-related progress notes, and ongoing treatment orders, including daily cleansing of a right medial/distal thigh lymphatic ulcer. Despite this, the Quarterly MDS, including Section M completed by an LPN, recorded that the resident had no skin ulcers, wounds, or skin problems. The wound was directly observed during survey, and the resident confirmed twice-daily wound care. Staff interviews revealed that the LPN believed the wound should have been coded as an open ulcer, the DON was unfamiliar with MDS accuracy implications, and the administrator acknowledged that inaccurate MDS documentation could affect care planning, contrary to facility policies requiring accurate, comprehensive assessments and documentation.
A resident with a right thigh wound related to lymphedema and a history of cerebral infarction and MRSA did not consistently receive ordered wound care. On one occasion, an LPN failed to perform the ordered wound treatment and documented an exception of the resident sleeping without follow-up or supporting progress notes. On later dates, another LPN documented completion of evening wound care, but the wound nurse observed the same dressing from the prior day still in place the following mornings, indicating the treatments were not actually done. These actions conflicted with the resident’s wound care orders, the care plan, and facility policies requiring accurate documentation of treatments and refusals.
Surveyors found that required daily nurse staffing and census information was not posted in a prominent location on one of the reviewed days. The ADMIN reported that the posting was usually placed outside the DON’s office and was typically the DON’s responsibility, but no current document was present. When a staffing document was produced, it was dated months earlier and did not break down staff numbers and hours by shift as required. The DON, recently hired, stated she was unsure who had previously been responsible for posting the information or when it was last posted, although a nursing schedule was kept at the nurses’ station. Facility policy required detailed, shift-specific staffing data to be posted within two hours of each shift’s start.
Two residents with PRN opioid orders for pain management were found to be missing one dose each of Tramadol and Hydrocodone from their narcotic blister packs, with the punched-out tablets not reconciled on the narcotic count sheets and MARs showing no administration on the date in question. Nursing documentation by an RN indicated it was unknown whether the PRN doses were actually given, and a medication aide later stated she could not remember if she administered the narcotics and admitted she did not document or reconcile the controlled medications during her shift. A prior shift narcotic count between an LVN and an RN had been correct, but the incoming medication aide took control of the cart without performing a narcotic count, and a subsequent LVN refused cart transfer when the discrepancies were discovered, demonstrating a failure to maintain accurate controlled drug records and reconciliation for these two residents.
A resident with intact cognition and surgical aftercare and gastrointestinal diagnoses brought a blister pack of diazepam (valium) into the facility after an outside urology visit and gave it to an unknown nurse. Later, the ADON found this controlled medication in a medication cart and discarded it into a biological waste box in the locked DON office, rather than placing it in the required double-locked narcotic storage and completing a narcotic sheet. During surveyor observation, the narcotic blister pack was found in the waste box with other medications and without any resident medication sheet, while all other narcotics in the locked cabinet were reconciled. Interviews with an LVN, pharmacist, administrator, and DON confirmed that controlled substances awaiting destruction must be stored under a two-lock system with corresponding documentation, and that this process was not followed in this case, contrary to the facility’s controlled substances policy.
A resident with advanced dementia was administered Donepezil 10 mg twice daily instead of the prescribed once daily dose for approximately two weeks, resulting in a worsening mental status. The error was not identified until a family member raised concerns about insurance coverage, leading to a review that confirmed the medication had been given at double the intended frequency.
Staff failed to consistently document wound care treatments as ordered for several residents with complex medical needs, resulting in incomplete treatment administration records. Interviews indicated that documentation lapses were due to workload and inconsistent record-keeping, with facility policy requiring all care to be recorded in the medical record.
A resident with advanced dementia received twice the prescribed daily dose of donepezil, resulting in worsening confusion and hospitalization. The facility did not report the significant medication error and injury to state authorities within the required timeframe, failing to follow its own policies and regulatory requirements.
The facility did not ensure its activities program was led by a qualified professional, as the current Activity Director lacked required training, certification, and experience. Interviews and record reviews confirmed that the individual in this role was not enrolled in any training and had no prior experience, affecting all residents reviewed.
A resident with morbid obesity, metabolic encephalopathy, and total dependence for several ADLs did not have a comprehensive, person-centered care plan that addressed required ADL assistance, cardiac diet interventions, or a weight management program. The care plan lacked measurable objectives, specific interventions, and did not reflect physician orders or the resident's actual care needs, due in part to incomplete documentation, staff role confusion, and technical issues with the electronic medical record system.
A newly hired RN, lacking her own EMR login, documented an assessment for a resident using an LVN's profile, resulting in inaccurate and incomplete medical records. The RN was shadowing the LVN and was allowed to use the LVN's credentials, but the LVN was unaware of the documentation being entered. Facility policy requires that only licensed personnel document under their own credentials, and this incident led to improper attribution of a resident's medical record entry.
A resident with chronic venous insufficiency did not receive wound care and compression therapy as ordered by the physician. Instead of applying TED hose as directed, staff left discontinued unna boot dressings on the resident's legs for over 30 days, which were observed to be dirty and unchanged. Staff interviews revealed a lack of communication and documentation regarding the change in orders, and the resident reported never being offered the TED hose.
Surveyors found that the kitchen's produce refrigerator contained three boxes of produce, including salad lettuce, shredded lettuce, and diced green cabbage, all stored past their labeled best by dates and still available for serving. The Food Service Manager confirmed the produce was not safe to serve and acknowledged responsibility for daily review and disposal of expired items, in accordance with facility policy.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
The facility did not maintain all equipment in safe working order, as evidenced by a commercial dishwasher with a malfunctioning temperature gauge and a resident bed left without a mattress for an extended period. Staff were aware of both issues, but appropriate maintenance and timely corrective actions were not documented or completed.
Surveyors found that in several rooms, call light cords in resident bathrooms were wrapped around metal bars, making them unreachable from the floor and preventing activation of the call system when pulled. The DON stated this was done to prevent slips, but acknowledged it could create a safety risk. Facility policy required accessible call systems, but the observed setup did not comply.
A resident with severe cognitive impairment and aphasia was slapped in the face by another cognitively impaired resident. The incident was witnessed by an LVN, who separated the residents and notified facility management and responsible parties. However, the event was not reported to the State Survey Agency as required, due to the belief by the DON and Administrator that there was no willful intent. No corresponding report was found in the state incident portal.
A resident with venous insufficiency and peripheral vascular disease was observed with continuous unna boot compression dressings on both legs, which were not documented in the MDS or skin assessment. The dressings were found to be discolored, dirty, and in direct contact with the floor over consecutive days. Interviews confirmed the omission in documentation, contrary to facility policy requiring accurate and comprehensive assessments.
A resident admitted with a traumatic subdural hemorrhage and cognitive communication deficit did not have a comprehensive baseline care plan developed within 48 hours of admission. The only documented care area was code status, omitting essential information such as allergies, fall risk, and therapy needs, as confirmed by interviews with the MDS nurse and DON.
A resident with a history of upper arm fracture and moderate cognitive impairment did not receive a physician-ordered house shake supplement with breakfast, as required for her therapeutic diet. Observations showed the kitchen lacked house shakes, and the supplement was missing from the resident's tray. Staff interviews revealed confusion over responsibility for providing the supplement, and the RD was unaware it was not being given.
A resident with multiple medical conditions was given amlodipine for hypertension without consistent documentation of blood pressure readings as required by physician orders. Despite staff claims that blood pressure was checked before administration, records did not reflect this, and the facility's policy to verify vital signs prior to medication administration was not followed.
A medication cart on the 200 hall was found unlocked and unattended near the activities room, with an LVN stating she thought it was locked when she walked away. The DON confirmed that facility policy requires medication carts to be locked when not in use, and staff interviews acknowledged the lapse in securing the cart.
Staff failed to perform proper hand hygiene between glove changes while providing indwelling catheter care to a resident with benign prostatic hyperplasia. Despite changing gloves during the procedure, hand hygiene was not performed as required by facility policy, a lapse confirmed by both the CNAs involved and the DON during interviews.
Staff failed to follow infection control protocols by not sanitizing a blood pressure cuff between use on two residents and by not performing hand hygiene between feeding three residents. Both the MA and LVN involved had received training and were assessed as competent in infection control practices, but did not adhere to facility policy during the observed care activities.
The facility did not ensure complete and accurate documentation of pain assessments, PRN pain medication administration, and weekly skin assessments for two residents. One resident with severe cognitive impairment had pain assessments recorded as '0' despite staff observing pain behaviors and administering Tylenol, which was not documented on the MAR. Both residents had missing weekly skin assessment documentation in the EMR, even though staff indicated assessments may have been performed. Facility policies required thorough documentation, but these procedures were not consistently followed.
The facility did not post up-to-date nurse staffing and census information for four consecutive days, as required by policy. Observations showed that the posted document was outdated and missing shift-specific care details. Staff interviews confirmed the lapse was due to printer issues and changes in facility ownership, which disrupted access to necessary resources for posting.
A nurse initiated CPR on a resident with a documented DNR order after finding the resident unresponsive, without first checking the code status binder or being aware of the resident's advance directive. Despite attempts by other staff to communicate the DNR status, CPR was performed, causing the resident pain. The resident's DNR status was clearly documented in multiple records, but facility protocols for verifying code status prior to emergency intervention were not followed.
A medication aide left a laptop displaying PHI unattended and unlocked on a medication cart, allowing several staff members to pass by the exposed information for several minutes before it was secured by the DON. Interviews confirmed the computer should have been locked, and facility policy prohibits leaving secured applications unattended.
A resident with multiple chronic conditions and mild cognitive impairment had several complaints made on their behalf regarding care, staff responsiveness, and communication. These grievances, submitted through texts, emails, and verbal reports to the DON and previous Administrator, were not documented or processed according to the facility's grievance policy. The facility failed to initiate the required grievance process, resulting in the resident's concerns not being formally addressed.
The facility did not report suspected violations of abuse, neglect, or exploitation to the state agency within the required timeframe for two residents. In one instance, CPR was performed on a resident with a DNR order, and in another, multiple allegations of neglect communicated by a resident's representative were not reported. Staff interviews and record reviews confirmed that these incidents were not recognized or reported as required by facility policy.
The facility did not investigate or report allegations of abuse, neglect, or exploitation for two residents, including an incident where a resident with a DNR order received CPR and multiple complaints from a resident's representative about inadequate care. Despite receiving these allegations, staff did not initiate investigations or submit required reports to the state agency, as confirmed by record reviews and staff interviews.
Staff failed to keep medication and treatment carts locked and attended, leaving them unsecured in a hallway where multiple staff members passed by. Both a medication aide and an LVN left their respective carts unattended and unlocked, contrary to facility policy requiring all drugs and biologicals to be stored securely with access limited to authorized personnel.
Surveyors found that the facility did not follow food safety standards in a resident snack pantry refrigerator, where multiple containers of expired, unlabeled, or spoiled food were accessible. Staff were unaware of proper labeling and monitoring practices, and the FSM was not initially aware of his responsibility for this area. The facility's own policy for date marking and food safety checks was not being followed, resulting in unsafe food storage conditions.
The facility did not ensure proper infection control in the laundry department, as clean blankets were stored with soiled infectious laundry and laundry aides handled soiled items with only gloves and without full PPE. Staff had not received specific training on handling infectious laundry, and clean and soiled linens were not kept separate as required by facility policy. The DON and Administrator acknowledged these failures placed individuals at risk for cross-contamination.
A resident with leukemia and cellulitis did not receive prescribed wound care on two consecutive days due to an LVN forgetting the task. The resident's care plan required daily wound care, which was not administered, leading to a lapse in treatment. The resident reported the missed care and expressed concern over the lack of explanation. Interviews with staff confirmed the oversight, emphasizing the need to follow MD orders for proper healing.
The facility failed to complete initial comprehensive assessments for four residents within the required 14-day period after admission. These residents, with various health conditions, did not receive timely evaluations of their needs and preferences. Interviews revealed a lack of clarity and communication among staff regarding the responsibility for completing and signing the MDS assessments, leading to delays and non-compliance with federal regulations.
Two residents in a LTC facility had inaccuracies in their initial comprehensive assessments. One resident was incorrectly coded as having an indwelling catheter, while another's fall history was inaccurately documented, missing a fracture related to a fall. These errors were identified through record reviews and staff interviews, with the Regional MDS Coordinator acknowledging the mistakes. Despite the inaccuracies, staff believed the errors did not impact the residents' care.
The facility failed to implement comprehensive care plans for four residents, omitting critical details such as full code status and fall risk interventions. Despite residents having a history of falls and requiring assistance, their care plans lacked specific objectives and timeframes. Interviews with staff revealed inconsistencies in the care planning process and uncertainty about responsibility for reviewing care plans.
A facility failed to develop comprehensive care plans for three residents, resulting in multiple falls and injuries. One resident, admitted with a broken neck, experienced several falls, including one causing a subdural hemorrhage. Despite being high fall risks, the residents lacked documented interventions to prevent falls. Staffing issues, including the absence of an MDS Coordinator, contributed to the deficiency, leaving staff uninformed about necessary care interventions.
A resident with a history of falls and multiple diagnoses experienced five falls in a facility due to inadequate supervision and lack of a comprehensive care plan. Despite being identified as a high fall risk, interventions were not documented, and staff were unaware of fall prevention measures. The facility's electronic records were not updated, and the DON was overwhelmed with duties, impacting the implementation of fall prevention strategies.
The facility failed to ensure RN certification of MDS assessments for two residents, resulting in overdue and incomplete assessments. Staffing shortages led the DON to work night shifts, leaving MDS oversight to corporate staff. The Corporate MDS nurse, an LVN, was overwhelmed with responsibilities across multiple facilities, leading to a lack of communication and oversight. This resulted in incomplete and uncertified MDS assessments.
A resident did not receive her scheduled dose of oxycodone before rehabilitation due to the facility's failure to maintain an adequate supply. The resident, recovering from knee replacement surgery, expressed anxiety about therapy without the medication. The LVN, new to the facility, did not use the emergency kit containing oxycodone. The DON acknowledged technical difficulties with the pharmacy system, which contributed to the issue.
The facility failed to employ a certified Dietary Manager or Registered Dietician to oversee food and nutrition services, as required. Interviews revealed that the facility had not had a Dietary Manager since opening, and a staff member considering the role was not yet trained or enrolled in necessary classes. The Registered Dietician provided remote services without in-person oversight. This deficiency could risk residents' nutrition and safety.
The facility failed to hire an onsite MDS Coordinator, resulting in incomplete and unverified MDS assessments and care plans. The Corporate MDS nurse, responsible for these tasks, was unavailable and unable to manage the workload due to overseeing multiple facilities. The facility, newly licensed, faced staffing shortages, with the DON working night shifts and unable to perform regular duties. Despite awareness of these issues, the facility had not hired an MDS Coordinator, and the Corporate HR Director only placed an ad for the position after the surveyor's entrance.
Failure to Maintain Required Full-Time Social Worker Coverage
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having a licensed capacity of 130 beds, exceeding the 120-bed threshold that requires a full-time social worker. Review of the SSA Facility Summary Report showed the facility’s licensed capacity and license expiration date, and review of the staff roster provided on 3/17/2026 revealed no staff member with the position title of social worker. Human Resources reported that the last full-time social worker resigned in mid-December 2025 and that there was no social worker on a full- or part-time basis from that time until 3/16/2026. During this period without a social worker, RN A, who had been acting as interim ADON, stated she attended care plan meetings but that no one had been assigned to perform the social worker duties in those meetings. A licensed social worker interviewed on 3/18/2026 reported he began working part-time on 3/16/2026 and confirmed that prior to that date no one was maintaining the social worker’s responsibilities, and he was then working on uncompleted reports and residents’ discharge needs. He stated that not having a social worker could result in residents’ discharge needs not being met or unidentified admission, discharge, or social barriers affecting their care. The interim Administrator confirmed he had just started on 3/16/2026 and that the facility only had a part-time social worker at that time.
Inaccurate MDS Pain Management Assessment for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s pain management status. The quarterly MDS submitted on 1/1/2026 for Resident #1 documented in section J0100 that the resident had not received a scheduled pain medication regimen and had not received or been offered PRN pain medications in the prior five days. This documentation conflicted with the resident’s medical record, which showed active physician orders for multiple scheduled and PRN pain medications, including acetaminophen PRN, methocarbamol scheduled at bedside and PRN, pregabalin three times daily for drug-induced polyneuropathy, and tramadol at bedtime for pain. The resident’s care plan also identified acute pain and osteoporosis, with an intervention to give analgesics PRN for pain. Resident #1 was a female with diagnoses including unspecified pain and drug-induced polyneuropathy, and her quarterly MDS reflected a BIMS score of 14, indicating intact cognition. In an interview, she reported having neuropathy, taking Lyrica (pregabalin) and tramadol on a scheduled basis three times a day, and using additional PRN doses several times a week, stating that this regimen had been consistent for several years and effectively controlled her pain. The MDS nurse stated she was primarily responsible for MDS completion but had been out on leave and did not complete the 1/1/2026 MDS for this resident. After reviewing section J0100, she acknowledged that it contained inaccurate information and stated that the MDS should be completed accurately in accordance with the facility’s comprehensive assessment policy and for accurate reimbursement and evaluation of residents’ long-term needs.
Incomplete and Missing Clinical Documentation for Treatments, Tube Feeds, IV Antibiotics, and Weights
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized clinical records for multiple residents, as required by professional standards. For one cognitively intact female resident with a right medial thigh lymphatic ulcer present on admission, the Treatment Administration Records (TARs) for January and February showed multiple blanks where daily and bedtime wound care orders were scheduled. Specifically, there were no documented wound treatments on numerous ordered dates and times, and progress notes did not reflect that wound care was performed on those dates. The facility’s wound care policy required documentation of the date wound care was given, the initials of the person performing the care, and notation of refusals, but this information was missing for several ordered treatments. Interviews with the wound care nurse, ADON, DON, and administrator confirmed that a blank on the record was interpreted as care not done or not documented, and one nurse acknowledged she believed she may have missed at least one scheduled wound care treatment during a busy period. The same resident’s diagnosis list was also incomplete. Multiple wound-related documents, including a wound NP note, wound assessment reports, and a physician progress note, identified the right medial thigh wound as a lymphatic ulcer associated with lymphedema. However, the resident’s Medical Diagnosis tab did not list lymphatic ulcer or lymphedema as diagnoses. The DON stated that diagnoses should be added when new issues arise or persist and acknowledged that lymphedema should have been part of this resident’s diagnosis list. The administrator similarly stated that not having a diagnosis listed might impact a resident’s treatment. For a second female resident with metabolic encephalopathy, protein-calorie malnutrition, dysphagia, and a PEG tube, the Medication Administration Records for January and February showed blanks on several days when continuous enteral feeding at a specified rate was ordered. On some dates, an exemption code of “Other / See Progress Notes” was used, but corresponding progress notes did not consistently document that tube feeding was provided or explain the exemption. On other dates, there were no entries at all for the scheduled tube feeding, and progress notes did not document that the feeding was given. The DON reported she closely monitored this resident’s tube feeding and believed no feedings were missed, but acknowledged that staff may not have charted when the feed was already running at the scheduled time and stated her expectation that staff still document the administration. For a third male resident with a history of intracerebral hemorrhage and UTIs, the Medication Administration Records for an IV imipenem-cilastatin order scheduled four times daily showed missing documentation at specific 5:30 p.m. doses on three separate dates. One of these times was coded as “Other / See Progress Notes,” but there were no corresponding progress notes documenting the IV antibiotic administration at that time, and the other two times were left blank with no entries. The facility’s medication administration and medication error policies defined medications as to be administered as ordered and identified omissions as medication errors, but the clinical record did not show that the ordered IV doses were given or refused, nor did it provide explanatory documentation. For a fourth cognitively intact female resident with COPD, anxiety disorder, and protein-calorie malnutrition, the record showed failures in weight documentation. The care plan included interventions to monitor and evaluate the resident’s weight, and a physician order required weekly weights. However, the weekly weight was not documented for one of three weeks in the specified period, and a separate order to obtain a weight on a specific date was entered and confirmed but not documented as completed in the record. Additionally, the resident’s weight was not documented on two dates as required by the care plan and physician order. The Order Summary Report did not reflect current active orders regarding weight monitoring, and the clinical record lacked the required weight entries on the ordered dates.
Inaccurate MDS Coding of Existing Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the presence of an existing wound. The resident, a female with diagnoses including cerebral infarction, rash and other nonspecific skin eruption, and MRSA infection, was admitted with a right thigh wound. Her Quarterly MDS assessment, dated 12/23/2025 and signed complete on 01/12/2026, documented that she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers. However, Section M – Skin Conditions, completed by an LPN on 01/01/2026, indicated that she had no skin ulcers, wounds, or skin problems. Contrary to the MDS coding, multiple clinical records showed the resident had an ongoing right medial/distal thigh wound. The care plan included a focus on wound management with an intervention to provide wound care per treatment order initiated on 11/04/2025. A nurse practitioner progress note dated 12/04/2025 referenced a right lower extremity thigh wound with MRSA. A skin issues progress note documented an abscess on the right medial thigh, and wound care orders on the Treatment Administration Record throughout January directed cleansing of a right distal thigh wound for a spider bite and later for lymphedema, with ongoing treatments and no discontinue date for some orders. A specialized skin and wound note dated 01/02/2026 described a pre-existing right medial thigh ulcer characterized as a lymphatic ulcer, and a wound assessment report dated 01/28/2026 identified the right medial thigh wound as a lymphatic ulcer acquired on 12/03/2025. Surveyor observations and staff interviews further confirmed the presence of the wound and the inaccuracy of the MDS. On 02/06/2026, an LPN was observed performing wound care on a small wound on the resident’s right inner thigh, and the resident reported that staff performed wound care twice daily and that treatments had not been missed. The LPN wound nurse stated the resident had been admitted with the thigh wound, initially thought to be lymphatic. The LPN who completed Section M of the MDS did not recall the resident but stated she believed the wound should have been coded as an open ulcer and that she would normally refer to the RAI manual if a wound did not fit standard options. The DON reported being unfamiliar with MDS assessments or how assessment accuracy could impact care, while the administrator acknowledged that inaccurate MDS wound documentation could affect care planning because MDS entries trigger care plan development. Facility policies required comprehensive assessments per the RAI Manual and complete, accurate documentation, but the resident’s wound was not coded on the Quarterly MDS despite extensive documentation of its presence and treatment.
Missed and Falsely Documented Wound Care Treatments for Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care treatment according to physician orders, the resident’s comprehensive care plan, and professional standards of practice for one resident. The resident was an adult female with diagnoses including cerebral infarction, rash and nonspecific skin eruption, and MRSA infection. A quarterly MDS showed she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers but had no documented skin ulcers at that time. Her care plan included a focus on wound management with an intervention to provide wound care per treatment order. Physician orders and treatment records showed that the resident had an order to cleanse a right distal thigh wound related to lymphedema. An order for once-daily wound cleansing was active in January, and a new order for wound care at bedtime, and later twice daily due to drainage, was active from late January onward. On one January date, the Treatment Administration Record reflected that the wound care was not completed and an exception code of "Sleeping" was entered and signed by an LPN. There was no corresponding progress note documenting the missed treatment, any resident refusal, or other explanation on that date. During interview, the LPN later acknowledged she believed she might have missed one of the resident’s scheduled wound care treatments while assisting on the floor and being behind on medications, and she described the resident as not allowing wound care after a certain evening time. In early February, the Treatment Administration Record showed that another LPN documented completion of the resident’s bedtime wound care on two evening shifts. However, the wound care nurse reported that on the mornings following those shifts she observed the same bandage she had applied the prior day still in place, indicating the ordered evening wound care had not been performed despite being charted as completed. She stated she had noticed evening wound care being missed a few times and had not yet reported these findings. On observation, the resident’s wound was small and located on the right inner thigh, with the dressing dated the previous day. The resident reported that staff were performing wound care twice a day and denied any concerns or awareness of missed treatments. The wound care NP stated the wound was not progressing well and there was concern for possible infection, and she was not aware of missed treatments because the wound was always dressed when she assessed it. The DON and the administrator both stated that sleeping was not an acceptable reason to omit wound care without follow-up, and facility policies on wound care and charting required accurate documentation of treatments, refusals, and related resident information, which was not done in these instances.
Failure to Post Required Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information in a prominent location for at least one of three days reviewed. On 02/04/2026, during an afternoon tour, surveyors were unable to locate any document displaying the daily census and nurse staffing information. Later that day, the Administrator stated that the daily census and nurse staffing posting was usually placed in a clear display holder outside the DON’s office and that it was typically the DON’s responsibility to post the document. The Administrator explained that, in the absence of the posting, residents and visitors could ask to view the nurse staffing schedule kept at the nurses’ station. When asked to provide the staffing posting, the Administrator produced a document labeled with the facility name and dated 12/19/2025. This document listed, by staff type (RNs, LVNs, CNAs, medication aides, and staff training), the number of staff, hours scheduled, and total hours worked, as well as the total hours worked for the day and the daily census; however, it did not break down the information by shift as required. The Administrator acknowledged the document was probably not completed correctly. In a subsequent interview, the DON, who had been in her role for just over one month, reported she did not know who had previously been responsible for posting the daily census and nurse staffing document or when it was last posted, though she confirmed that the nursing schedule was always available at the nurses’ station. Review of the facility’s policy "Posting Direct Care Daily Staffing Numbers" showed that the facility was required to post, within two hours of the beginning of each shift, detailed nurse staffing data by shift, including staff type, category, and actual time worked, in a prominent, accessible location.
Unreconciled Missing Narcotics and Inadequate Controlled Drug Accounting
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of controlled drugs for two residents. For Resident #1, a female with a history including lumbar vertebra fracture, cellulitis, difficulty walking, and cognitive communication deficit, the care plan included a goal of pain management with opioid medications. Physician orders dated December 1, 2025, included Tramadol 50 mg every four hours PRN, and the December 2025 MAR showed no Tramadol administered on 12/23/25. Review of the resident’s Tramadol 50 mg narcotic blister pack revealed one tablet was punched out but not reconciled with the narcotic count sheet, and an Orders Administration Note authored by RN A on 12/23/25 at 5:53 AM documented that it was unknown whether the resident received the PRN Tramadol on that date. For Resident #2, a female with diagnoses including pulmonary embolism, urinary tract infection, and cognitive communication deficit, the care plan also included a goal of pain management with PRN Hydrocodone every six hours. Physician orders dated December 1, 2025, reflected Hydrocodone 10-325 mg PRN every six hours for pain. Review of Resident #2’s Hydrocodone 10-325 mg narcotic blister pack showed one tablet punched out that was not reconciled with the narcotic count sheet. An Orders Administration Note dated 12/23/25 at 5:53 AM by RN A similarly reflected that it was unknown whether the resident received the PRN Hydrocodone on that date. The facility’s internal investigation file documented that it was alleged that one Tramadol and one Norco were missing for these two residents and that reconciliation sheets were not completed. Staff interviews and documentation further described the actions and inactions that led to the discrepancy. A written statement by RN A on 12/23/25 confirmed there were two missing narcotics involving these residents. A written statement by MA B on 12/23/25 indicated that MA B could not remember whether the narcotics were given and admitted to not documenting or reconciling narcotic medications on 12/23/25. The Administrator’s timeline indicated that LVN C reconciled the narcotic count with RN A at the end of her shift, showing that the residents had received PRN narcotics on 12/22/25, but when MA B arrived later and took possession of the medication cart, she did so without reconciling the narcotic count with RN A. Later, during an attempted cart transfer, LVN D refused to accept the cart because two controlled substances for these residents were not accounted for. In a subsequent interview, MA B stated she did not count the narcotic medications because she was overwhelmed and distracted, noticed the missing medications at shift change, and maintained she did not administer the missing doses, while also acknowledging that the narcotic counts had not been reconciled. The facility’s policy on Drug Discrepancies/Diversion of Medications stated that all discrepancies, suspected loss, and/or diversion of medications are to be immediately investigated and reported, underscoring that the missing and unreconciled narcotics constituted a failure to maintain drug records in proper order and to account for all controlled drugs.
Improper Storage and Documentation of Controlled Substance Intended for Destruction
Penalty
Summary
The deficiency involves the facility’s failure to properly store a DEA-controlled substance (diazepam/valium) intended for destruction in accordance with its policy and professional standards. Surveyor observation of the medication carts and the medication/drug storage room showed that narcotic medications in the locked narcotic cabinet were reconciled and stored under a double-lock system in the DON’s office. However, a biological waste box in the same locked room contained multiple medications and one narcotic blister pack of diazepam 5 mg, prescribed as 1 tablet PRN 30 minutes prior to imaging for Resident #3, without an accompanying resident medication sheet. Record review showed no physician order or administration record for diazepam for this resident in December 2025. Staff interviews confirmed that this narcotic blister pack was not stored in the required double-locked container and lacked the required resident sheet. Resident #3 was an adult male with diagnoses including surgical aftercare on the digestive system, vertigo, and intestinal obstruction, with a BIMS score of 13 indicating no cognitive impairment and requiring only supervision for transfers and mobility. The resident reported bringing a urologist-prescribed blister pack medication into the facility around New Year and giving it to an unknown nurse, and did not recall the purpose of the medication or whether he received any doses. The ADON stated that the resident returned from pass with diazepam and gave it to an unknown nurse, and that she later found the medication in a medication cart and threw it into the biological waste box in the locked DON storage room instead of placing it in the double-locked narcotic container or completing a resident narcotic sheet. The LVN, pharmacist, administrator, and DON each confirmed that controlled substances scheduled for destruction were required to be stored in a two-lock system with a corresponding resident sheet, and that the facility’s practice in this instance did not follow those procedures. The facility’s Controlled Substances policy stated that controlled substances remaining after discontinuation or discharge are to be securely locked in an area with restricted access until destroyed.
Significant Medication Error: Double Dosing of Donepezil
Penalty
Summary
A deficiency occurred when a resident was administered Donepezil HCL Oral Tablet 10 mg twice daily for approximately two weeks, despite the physician's order specifying a dose of 10 mg once daily. This error was identified through observation, interview, and record review, which revealed that the medication was given at double the prescribed frequency from 11/14/2025 to 11/26/2025. The error was discovered after the resident's family reported insurance would not cover more than one tablet per day, prompting a review of the medication orders and administration records. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and nutritional problems. During the period of the medication error, the resident experienced a worsening mental status, as documented in a hospital report, which noted that the increase in Donepezil dosage coincided with the decline in mentation. The resident was alert only to person at the time of hospital evaluation, and no other sources of infection or acute illness were identified as contributing factors. Facility records showed that the medication order for Donepezil was incorrectly entered into the electronic medical record (EMR) as 10 mg twice daily, despite a dose warning indicating that this frequency exceeded the usual recommendation. The error persisted until it was recognized and the resident was subsequently sent to the hospital for evaluation. Interviews with staff confirmed that the error was not identified until after the family inquiry, and that the physician and pharmacy were notified only after the error was discovered.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six out of eight residents, specifically regarding the documentation of wound care treatments as ordered in the electronic medical record. For multiple residents, staff did not mark the completion of wound care treatments on specific dates, despite physician orders requiring daily or scheduled wound care. The treatment administration records (TARs) for these residents contained blanks where documentation of wound care should have been recorded, indicating either the care was not provided or not documented. Residents affected had various medical conditions, including cirrhosis of the liver, atherosclerosis with gangrene, spinal stenosis, and cerebral infarction. For example, one resident with a right-hand skin tear did not have wound care documented on three separate days, while another with an above-knee amputation and groin wounds had missing documentation on four days. Other residents with surgical wounds, scalp lesions, and staples also had incomplete wound care documentation on multiple dates as required by their treatment orders. Interviews with staff revealed that nurses sometimes found it difficult to document every treatment due to workload, and that blanks in the TAR could mean either the care was not completed or simply not recorded. The Assistant Director of Nursing acknowledged that blanks in the records signified wound care was not documented and noted that some staff had been disciplined for not completing electronic medical record entries. The facility's own policy requires that all treatments and services provided to residents be documented in the medical record to facilitate communication among the care team.
Failure to Timely Report Medication Error and Resulting Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent neglect by not ensuring that all alleged violations involving neglect were reported immediately, as required. Specifically, a significant medication error occurred when a resident received twice the ordered daily dose of donepezil, a medication for dementia, which led to worsening confusion and necessitated hospitalization. The error was discovered after the resident exhibited a decline in mental status, but the incident was not reported to the appropriate state authorities (HHSC) within the required two-hour timeframe after discovery. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and harm as documented in her care plan. Medical records showed that the resident's donepezil dosage was increased in error, and the medication administration record included a warning that the frequency exceeded the usual daily dose. Despite these indicators and the resident's subsequent hospitalization for altered mental status, the facility did not report the medication error and resulting injury as required by policy and regulation.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required. Record review and interviews revealed that the individual serving as Activity Director did not possess the necessary qualifications, training, or certification. The Activity Director had been in the position for 4-5 weeks, had no prior experience, was not an occupational therapist or occupational therapy assistant, and was not enrolled in any training program for the role. The HR Director confirmed that there was no proof of education or training in the personnel file, and the Administrator acknowledged that the Activity Director was not currently registered for any required training and that no one else at the facility met the qualifications for the position. The facility's job description for the Activity Coordinator did not specify required qualifications, and the policy on the activity program did not address the qualifications for the Activity Director. The Administrator and Activity Director both stated that the current Activity Director was initially hired as an assistant and was performing the role on a trial basis, with intentions to pursue certification in the future. As a result, 72 out of 72 residents reviewed were affected by the lack of a qualified professional directing the activities program.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. The resident, a male with morbid obesity, a BMI between 50.0-59.9, and metabolic encephalopathy, was admitted with significant impairments in mobility and required total dependence for several activities of daily living (ADLs) such as toileting, bathing, and lower body dressing. Despite these needs, the care plan lacked specific interventions for required ADL care and assistance, did not specify the number of staff needed for care, and failed to provide measurable objectives or timeframes for meeting the resident's needs. The care plan also included only placeholder information for bed mobility and did not address the resident's total dependence or the level of assistance required. Additionally, the care plan was incomplete regarding the resident's nutritional needs. Although there was a physician order for a cardiac diet and semaglutide for weight management, the care plan did not include interventions for the cardiac diet or a weight management program. There was no direction on ideal nutritional intake, weight goals, or monitoring strategies. Interviews with staff revealed that the resident was allowed to eat snacks in addition to the prescribed diet, and staff were expected to monitor and record food intake, but these practices were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan was incomplete and lacked necessary details, attributing this to being new in the role and the absence of regular care plan meetings. Further contributing to the deficiency, the facility experienced issues with their electronic medical record system, which resulted in baseline care plans being opened by LVNs and required manual intervention to create comprehensive care plans. The DON and other staff confirmed that these technical issues, along with unclear responsibilities and lack of regular oversight, led to incomplete care plans. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not achieved for the resident in question.
Inaccurate Medical Record Documentation Due to Improper EMR Access
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, resulting in incomplete and inaccurate documentation for one resident. Specifically, a newly hired RN, who did not have her own login credentials for the electronic medical record (EMR) system, was allowed to document an assessment note for a resident using an LVN's profile. The progress note in question was electronically signed and time-stamped under the LVN's credentials, although the content was authored by the RN. The RN stated she was shadowing the LVN to learn the computer system and was permitted to use the LVN's profile, but the LVN was not present when the documentation was entered and was unaware that the RN was making entries in the medical record. The LVN later discovered the note and reported it to the Director of Nursing (DON). Interviews with facility staff revealed that the RN was new, had not been fully trained, and was not authorized to chart independently. The Assistant Director of Nursing (ADON) and DON both confirmed that documentation under another staff member's credentials was not permitted and constituted a violation of facility policy, which requires that entries in the medical record be objective, complete, accurate, and only recorded by licensed personnel under their own credentials. The resident involved was an elderly female with multiple diagnoses, including urinary retention, type 2 diabetes mellitus, and hypertension. The incident resulted in inaccurate attribution of documentation in the resident's permanent medical record.
Failure to Provide Wound Care and Follow Physician Orders for Compression Therapy
Penalty
Summary
A male resident with a history of venous insufficiency and peripheral vascular disease was admitted to the facility and had physician orders for TED hose to be applied daily for edema management, with documentation required if refused. Despite these orders, there was no evidence on the treatment administration record that the TED hose were applied, and staff interviews revealed that the resident was not offered the TED hose, nor were they present in his room. Instead, the resident continued to wear unna boot compression dressings, which had been discontinued by physician order, for over 30 days. The dressings were observed to be dirty, discolored, undated, and in direct contact with the floor, and had not been changed since their application. Staff interviews indicated a lack of communication and follow-through regarding the change in orders from unna boots to TED hose. The wound care nurse (WCN) was unaware that the resident still had the unna boots on, and the primary nurse did not ensure their removal. The nurse practitioner and DON were also unaware of the resident's continued use of the unna boots and the lack of TED hose application. The resident denied refusing the TED hose and stated that staff had not offered them. Facility policy did not provide guidance on discontinuing wound care orders, contributing to the failure to provide care in accordance with physician orders and the resident's care plan.
Expired Produce Stored in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to store and manage food in accordance with professional standards for food service safety. During an inspection of the kitchen's produce refrigerator, three boxes containing a total of 60 pounds of produce (salad lettuce, shredded lettuce, and diced green cabbage) were found to be stored past their labeled 'best by' dates. The produce was still available for serving to residents at the time of the observation. The Food Service Manager (FSM) confirmed during an interview that the produce was beyond the best by date and acknowledged it was not safe to serve. The FSM stated that it was his responsibility to review the produce daily and discard any items past their best by date, as per facility policy. The facility's Food Receiving and Storage policy requires that refrigerated foods be labeled, dated, monitored, and either used by their use-by date, frozen, or discarded. The Administrator also confirmed the expectation that no foods should be kept past expiration or best by dates. The failure to follow these procedures resulted in the deficiency cited by surveyors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe and Functional Equipment
Penalty
Summary
The facility failed to ensure that all mechanical, electrical, and patient care equipment was maintained in safe operating condition. Specifically, the commercial electric dishwasher in the kitchen had a malfunctioning temperature gauge, which had been reading below the manufacturer's required minimum of 120°F for effective sanitization. Dietary staff and the Food Service Manager (FSM) were aware of the issue, and logs showed temperature readings ranging from 100°F to 120°F. Although a handheld thermometer showed the water temperature was sufficient, the built-in gauge had been malfunctioning since April, and there was no documented evidence of a maintenance technician's visit or a work order to address the problem. Additionally, one of two beds in an occupied resident room was found without a mattress for approximately a month following the passing of a hospice resident. Staff interviews revealed uncertainty about why a new mattress had not been placed on the bed, and the Director of Nursing (DON) acknowledged awareness of the risk posed by an exposed metal bed frame. The facility's equipment safety and maintenance policy required prompt reporting and addressing of equipment malfunctions, but these procedures were not effectively followed in these instances.
Inaccessible Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was accessible in each resident's bathroom and bathing area for 11 out of 15 rooms reviewed. Observations revealed that in multiple rooms, the call light cords were wrapped around the metal assistance bars next to the toilets, making them unreachable from the floor and approximately two feet above the ground. When attempts were made to pull the call light cords from the floor, the system did not activate, as the tension was absorbed by the metal bar rather than triggering the call system. Further observations confirmed that the call system functioned only when the cords were pulled without obstruction. During an interview, the DON explained that the cords were wrapped around the bars to prevent residents from slipping on them, acknowledging that this practice could pose a safety risk by making the call system inaccessible in emergencies. The facility's policy required that each resident have a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor, but the observed practice did not comply with this policy. No incidents of falls with inability to use the call system were reported at the time of the survey.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident occurred in which a resident with severe cognitive impairment and aphasia was slapped in the face by another resident, who also had severe cognitive impairment. The incident was witnessed by an LVN, who immediately separated the residents and notified the Director of Nursing (DON), Administrator, physician, and both residents' responsible parties. Documentation in the progress notes confirmed the incident and the actions taken at the time. Despite these actions, the incident was not reported to the State Survey Agency as required by federal regulations. The DON and Administrator stated during interviews that they did not report the incident because they believed there was no willful intent from the resident who committed the act, citing the resident's BIMS score of 0 and lack of prior behavioral issues. A review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no report corresponding to this incident was submitted. The facility's policy required investigation and reporting of any allegations within the federally mandated timeframes, which was not followed in this case.
Inaccurate MDS Assessment and Documentation of Compression Dressings
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with venous insufficiency and peripheral vascular disease. The annual MDS for this resident did not document the presence of continuous compression dressings, specifically unna boot dressings, which were observed on both legs during surveyor observations. The MDS indicated that no non-surgical dressings were applied, and the skin assessment did not note any alterations or the presence of dressings. Surveyors observed the resident wearing discolored and dirty dressings on both legs, extending from mid-foot to the knee, with the dressings in direct contact with the floor and not dated. These observations were made on consecutive days, and the condition of the dressings remained unchanged. Interviews with the MDS nurse and the Director of Nursing confirmed that the dressings should have been documented in the MDS and that nursing assessments are expected to accurately reflect the resident's status. Facility policy requires comprehensive assessments to be conducted and coordinated by a registered nurse with input from the interdisciplinary team.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the only item addressed in the baseline care plan was the resident's full code status, with no documentation of other essential care areas such as allergies, fall risk, skin conditions, bowel and bladder needs, pain management, or nutrition. The resident in question was admitted with significant medical needs, including a traumatic subdural hemorrhage and a cognitive communication deficit, and was discharged to an acute care hospital after 10 days. Interviews with facility staff, including the MDS nurse and the DON, confirmed that the baseline care plan was insufficient and did not meet professional standards for person-centered care. The MDS nurse stated that the care plan should have included comprehensive information to guide care, and the DON acknowledged that the document was lacking critical details such as medications, transfer status, and therapy needs. The facility's care planning policy did not address baseline care planning for new admissions.
Failure to Provide Ordered Nutritional Supplement to Resident
Penalty
Summary
The facility failed to ensure that a resident with a nutritional problem received a therapeutic diet as ordered by the healthcare provider. Specifically, a female resident with a history of a right upper arm fracture and moderately impaired cognition was prescribed a regular diet with the addition of a house shake at breakfast and whole milk with dinner to support healing and optimal nutrition. Despite these orders, observations revealed that the kitchen did not have house shakes available, and the resident's breakfast tray did not include the required supplement. The resident confirmed she had not received the house shake at any point since admission. Interviews with staff indicated a lack of clarity regarding responsibility for providing the house shake, with dietary staff expected to include it on the tray and nursing staff expected to verify its presence. The registered dietitian confirmed the recommendation for the house shake and was unaware it had not been provided. The director of nursing also stated that dietary services should deliver the house shakes and that nursing should check for them before serving trays. The absence of the ordered nutritional supplement was confirmed through multiple observations and staff interviews.
Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A resident with a history of epilepsy, aphasia, and nontraumatic intracerebral hemorrhage was prescribed amlodipine for hypertension, with physician orders specifying that the medication should be held if the diastolic blood pressure was less than 110 mmHg or the systolic blood pressure was less than 60 mmHg. The resident's care plan included interventions to obtain and record blood pressure readings under consistent conditions before administering antihypertensive medications. However, review of the Medication Administration Records for May and June showed that the resident received amlodipine 42 times without documentation of blood pressure readings at the time of administration. The Blood Pressure Vitals Record indicated that blood pressure was only recorded five times during this period, despite daily administration of the medication. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the electronic health record may not have prompted staff to input blood pressure readings prior to medication administration. The LVN stated she checked the resident's blood pressure before giving the medication but could not provide evidence of this in the records. The facility's medication administration policy required verification of vital signs when necessary prior to administering medications, but this was not consistently documented or followed in this case.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart assigned to the 200 hall was observed left unlocked and unattended near the entrance closest to the resident activities room. The cart was not secured at the time of observation, and staff interviews confirmed that the cart was under the responsibility of an LVN who had walked away, mistakenly believing it was locked. Another staff member subsequently locked the cart after noticing it was unsecured. The Director of Nursing (DON) confirmed that the facility's expectation is for medication carts to be locked when not in use to prevent unauthorized access. Review of the facility's policy on medication labeling and storage, revised in February 2023, specifies that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. The failure to secure the medication cart was directly observed and acknowledged by staff, with the DON reiterating the importance of keeping medication carts locked to prevent unauthorized access.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during indwelling catheter care for a male resident with benign prostatic hyperplasia. During an observed care episode, two CNAs donned gowns and gloves before entering the resident's room. One CNA assisted the resident with transferring to bed and removing clothing, then initiated catheter care without changing gloves or performing hand hygiene. After cleansing the resident's thigh creases, the CNA disposed of soiled gloves but did not perform hand hygiene before donning new gloves. This process was repeated after cleansing the catheter tubing, with gloves changed but no hand hygiene performed between changes. Interviews with the involved CNAs and the DON confirmed that hand hygiene should have been performed between all glove changes, as per facility policy. The facility's standard precautions policy requires hand hygiene before and after resident contact and after removing gloves. The failure to follow these procedures was observed and acknowledged by staff, and the DON confirmed that not adhering to hand hygiene protocols could result in the spread of infection.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for five of seven residents reviewed. Specifically, a medication aide (MA) did not sanitize a wrist blood pressure cuff between use on two different residents, despite having received training and being assessed as satisfactory in infection control practices. The MA acknowledged forgetting to sanitize the equipment and recognized the risk of spreading germs. Both residents involved had diagnoses of hypertension and were receiving blood pressure monitoring and medication administration as part of their care. Additionally, a licensed vocational nurse (LVN) did not perform hand hygiene between feeding and assisting three different residents during breakfast. The LVN admitted to not washing or sanitizing her hands between residents, citing a desire to ensure timely feeding, and acknowledged awareness of infection control protocols. The LVN had previously been assessed as competent in hand hygiene and standard precautions. Facility policy required hand hygiene before and after resident contact and cleaning of reusable equipment between residents, but these protocols were not followed during the observed incidents.
Incomplete Documentation of Pain Management and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically in the areas of pain assessment, medication administration documentation, and weekly skin assessments. For one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and osteoporosis, pain assessments were documented as '0' on the Medication Administration Record (MAR) and Nursing Medication Administration Record (NMAR) during periods when staff interviews and progress notes indicated the resident exhibited signs of pain, such as grimacing and moaning. Despite staff acknowledging the resident's pain and administering Tylenol, the MAR entries for the administration of this PRN pain medication were left blank, and staff could not consistently recall or explain the lack of documentation. Additionally, the same resident's weekly skin assessments were not documented in the electronic medical record (EMR) for two of fourteen weeks, despite orders requiring weekly assessments. Staff interviews revealed confusion regarding the process for documenting skin assessments, with some nurses indicating that assessments may have been performed but not entered into the correct section of the EMR. The facility's management confirmed that if the MAR was checked as administered, it was assumed the assessment was done, but acknowledged that missing documentation in the assessment tab meant the findings were not recorded. A second resident, who was moderately cognitively impaired and at risk for pressure ulcers, also had missing documentation for weekly skin assessments for three weeks. While the MAR indicated that assessments were administered, there were no corresponding entries in the EMR assessment tab or progress notes for those weeks. Staff interviews suggested that assessments may have been completed but not documented, and management did not believe the lack of documentation impacted care, as they relied on the MAR check-off and the presence of a treatment nurse. Facility policies required comprehensive documentation of pain assessments, medication administration, and skin assessments, but these were not consistently followed.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or vocational nurses, certified nurse aides, and the resident census for four consecutive days. Observations on one of these days revealed that the most recent posted document was dated several days prior and did not include information regarding care provided per shift. Interviews with staff, including the LPN and DON, confirmed that the document was not updated or posted as required, and that the DON and weekend supervisor were responsible for this task. The DON acknowledged the document was outdated and attributed the failure to issues with the facility's printers and a recent change in ownership, which affected staff access to printing resources. A review of the facility's policy indicated that nurse staffing data should be posted daily for each shift within two hours of the beginning of each shift, in a prominent and accessible location. The policy also specified the required information to be included on the posting. Despite these requirements, the facility did not ensure the daily posting of current nurse staffing and census information for the reviewed period, as confirmed by both observation and staff interviews.
Failure to Honor Resident DNR Status During Emergency Response
Penalty
Summary
The facility failed to ensure that personnel honored a resident's advance directive regarding resuscitation. A resident with an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order and a documented DNR status in the medical record was found unresponsive. Despite the clear DNR status, a nurse initiated CPR and performed two chest compressions, causing the resident to moan in pain. The nurse admitted to not being aware of the resident's DNR status at the time and did not check the code status binder on the crash cart before starting CPR. The nurse only became aware of the DNR after a subsequent phone call with the physician and upon later review of the binder. Multiple staff interviews confirmed that the code status binder, which contains up-to-date information on all residents' resuscitation preferences, was available and located on the crash cart. However, the nurse involved did not consult this resource before acting. Other staff members, including CNAs, stated they attempted to communicate the resident's DNR status to the nurse during the event, but the nurse did not hear or respond to this information. The facility's policy required staff to check the code status before initiating CPR, but this protocol was not followed in this instance. The resident involved had a history of multiple rib fractures, dementia, Parkinson's disease, and cognitive impairment, and was admitted for rehabilitation. Documentation showed the resident's DNR status was consistently recorded in the admission record, care plan, and physician orders. The incident was not immediately reported to the state agency, and there was a lack of documentation and training regarding code status protocols among staff at the time of the event.
Unattended Laptop Exposes PHI of Multiple Residents
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal and medical records for 11 residents. During an observation, a medication cart was found unattended in a hallway with a laptop computer on top, actively displaying protected health information (PHI) for these residents. The laptop was left unsupervised and unlocked for at least five minutes, during which time several staff members, including a housekeeper, a driver, and a CNA, walked past the exposed information. The surveyor eventually alerted an LVN, who then notified the DON, resulting in the computer being locked and closed. Interviews with the DON and the medication aide assigned to the cart confirmed that the computer contained PHI and should have been secured when not attended. The medication aide stated she believed she had locked the computer and was unsure how it became open, acknowledging the risk to residents' privacy. A review of the facility's HIPAA Sanctions policy indicated that leaving a secured application unattended while logged on is a violation of facility policy.
Failure to Initiate and Document Grievance Process
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for at least one resident. Multiple complaints and grievances were made on behalf of a resident with significant medical conditions, including cerebrovascular disease, COPD, and cancer of the intestines. The resident's representative reported ongoing issues with care, communication, and staff behavior to the previous Administrator and the DON through various means such as text messages, emails, and verbal communication over a period of months. These complaints included concerns about pain management, staff responsiveness, changes in the resident's condition, and the handling of care plan documentation. Despite these repeated complaints, the facility did not initiate the formal grievance process as required by its policy. The complaints were acknowledged in some cases by the DON and the previous Administrator, but there was no evidence that the grievances were documented, investigated, or resolved according to the facility's procedures. The facility's grievance log did not contain any record of the grievances made on behalf of the resident during the relevant time period. Interviews with facility leadership confirmed that the staff did not recognize or act upon these grievances as required, and the DON admitted to not understanding the grievance process due to lack of training from the previous Administrator. The facility's own policy requires that all grievances be documented, investigated, and resolved promptly, with written decisions provided to the complainant. However, the actions of the previous Administrator and the DON did not meet these requirements, as they failed to record or process the grievances received. This lack of adherence to policy resulted in the resident's grievances not being formally heard or addressed, as confirmed by record reviews and staff interviews.
Failure to Timely Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to ensure that all suspected violations involving abuse, neglect, exploitation, or mistreatment were reported to the state agency within the required timeframe for two residents. In the first case, a nurse performed CPR on a resident who had a documented Do Not Resuscitate (DNR) order, despite the resident's wishes and clear documentation in the medical record and care plan. Staff interviews revealed that the nurse initiated CPR, and another staff member attempted to inform the nurse of the resident's DNR status during the event. The incident was not reported to the state agency as required, and there was no facility-generated report regarding this allegation of neglect for the resident during the relevant period. In the second case, the facility failed to report multiple allegations of neglect made on behalf of another resident. The resident's representative communicated concerns about inadequate pain management, lack of response from nursing staff, and failure to recognize significant changes in the resident's condition through text messages and emails to the previous Administrator and DON. These communications included specific allegations of neglect, such as staff not responding to call bells, not addressing the resident's deteriorating condition, and improper attempts to collect a urine sample. Despite these repeated allegations, there was no evidence that the facility reported them to the state agency as required. Interviews with facility staff, including the current Administrator and DON, confirmed that the previous leadership did not recognize or act upon these allegations as reportable events. The facility's own policies required immediate reporting of such allegations, but these procedures were not followed. The lack of timely reporting of suspected abuse, neglect, or exploitation could place residents at risk by failing to ensure that allegations are properly investigated by the appropriate authorities.
Failure to Investigate and Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, or exploitation (ANE) to the State Survey Agency within the required 5 working days for two residents. In the first case, a resident with a documented Do Not Resuscitate (DNR) order was subjected to CPR by a nurse, despite clear documentation and communication of the resident's DNR status. Staff interviews revealed that the nurse initiated compressions before being informed of the DNR status, and there was no subsequent investigation or report of this incident to the state agency. The Assistant Director of Nursing (ADON) acknowledged awareness of the code status incident but did not report it, and the previous Director of Nursing (DON) stated she was unaware of the event and would have reported it if informed. In the second case, a resident's representative made multiple allegations of neglect via text messages and emails to the previous Administrator and DON, including concerns about delayed pain medication, lack of recognition of significant changes in the resident's condition, and inadequate response to requests for care. Despite these communications, there was no evidence that the facility investigated these allegations or reported the results to the state agency. The DON and Administrator at the time received and acknowledged the complaints but did not initiate the required investigation or reporting process. Record reviews confirmed that no facility-generated reports regarding these allegations were submitted to the state agency during the relevant periods. Interviews with current and former staff indicated a lack of clarity and follow-through regarding responsibility for investigating and reporting ANE allegations. The facility's own policies required immediate investigation and reporting of such incidents, but these procedures were not followed in the cases reviewed.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them. During an observation, both a medication cart and a treatment cart were found unattended, unsupervised, and unlocked in a hallway. Over a period of five minutes, several staff members, including a housekeeper, a driver, and a CNA, walked past the unsecured carts. The medication aide assigned to the cart stated she always locked the cart when leaving it but was unsure how it became unlocked. The LVN responsible for the treatment cart admitted to unintentionally leaving it unlocked while providing care in a resident's room. The Director of Nursing (DON) and the Administrator were both made aware of the situation. The facility's policy requires all medications to be stored in locked compartments with access limited to authorized personnel. The failure to secure the medication and treatment carts was directly observed and acknowledged by the staff involved, with the risk for harm identified as unsecured medications.
Failure to Ensure Safe Storage and Labeling of Resident Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by observations in the resident food and snack pantry refrigerator. During an inspection, surveyors found 15 containers of food with various safety concerns, including expired items, unlabeled or improperly labeled foods, and visibly spoiled or malodorous contents. Specific examples included yogurt and fruit with past-due manufacturer dates, facility-made foods without discard dates, unmarked containers with spoiled contents, and leftovers from outside sources lacking proper labeling or dating. Staff interviews revealed a lack of awareness and adherence to food safety protocols. A CNA stated she was unaware of labeling practices and could not confirm the safety of the foods present, noting that some items appeared unsafe and would be reported to nursing staff. The Food Service Manager (FSM) was initially unaware of the existence of the resident snack pantry and its refrigerator, and only upon notification did he recognize his responsibility for food safety in that area. The FSM outlined expectations for labeling and discarding food, but these were not being followed at the time of the survey. A review of the facility's policy on date marking for food safety indicated that perishable foods should be held at 41°F or less, clearly marked with preparation and discard dates, and discarded within specified timeframes. The policy also assigned responsibility for daily and weekly checks to specific staff members. However, these procedures were not being implemented in the resident snack pantry, resulting in the presence of expired, spoiled, and improperly stored foods accessible to residents.
Failure to Prevent Cross-Contamination in Laundry Department
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the laundry department, specifically regarding the handling, storage, processing, and transport of linens. Observations revealed that clean blankets were stored in the soiled laundry room alongside boxes containing soiled infectious disease laundry. The soiled laundry room was also used to hang clean, wet blankets to dry, resulting in clean and soiled items being stored together. The soiled laundry was stored in cardboard boxes labeled as biohazard, and these boxes contained laundry from residents under isolation precautions due to infections. Laundry aides reported that the only personal protective equipment (PPE) available in the laundry department was gloves, and they did not use full PPE such as gowns when handling soiled infectious laundry. Both laundry aides stated they had not received specific training on handling soiled infectious disease laundry and relied on common sense and general hand hygiene practices. The Housekeeping Director confirmed that training for infectious disease prevention and control was outside his scope and that he had only received general infection control training from the DON, not specific to laundry procedures. The facility's infection prevention and control policy required that clean linen be separated from soiled linen at all times and that staff use PPE according to established policy. However, these procedures were not followed, as evidenced by the storage of clean blankets with soiled infectious laundry and the lack of appropriate PPE use by laundry staff. The DON and Administrator acknowledged that these practices placed residents and staff at risk for cross-contamination and infection.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care to a resident as ordered by the physician for cellulitis on two consecutive days. The resident, who was diagnosed with leukemia and cellulitis, did not receive the prescribed wound care on the specified dates. The resident's care plan included daily wound care, which was not administered on one of the days by an LVN who later admitted to forgetting due to being busy. The resident reported the missed care to a CNA and expressed concern about not receiving an explanation for the lapse in treatment. The resident's medical records indicated that wound care was not performed on the specified date, and the resident's skin assessment showed redness on the right leg without measurements. Interviews with the nursing staff, including the wound nurse and the DON, confirmed the oversight and highlighted the importance of following MD orders to ensure proper healing. The resident did not suffer any immediate harm, as the skin was intact, and the condition was being treated with antibiotics.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to conduct initial comprehensive assessments of residents' functional capacities within the required 14-day period after admission. This deficiency was identified for four residents, who were not assessed in a timely manner, potentially affecting their care and services. The MDS Coordinator did not complete the necessary assessments for these residents, which included evaluating their needs, strengths, goals, life history, and preferences. Resident #1 was admitted with multiple health conditions, including a fracture, respiratory failure, and chronic kidney disease. The MDS Admission/Medicare-5 Day assessment for this resident was completed and signed late, beyond the 14-day requirement. Similarly, Resident #2, diagnosed with depression, polyneuropathy, and a spinal fracture, had an incomplete MDS assessment that was not signed by an RN Assessment Coordinator. Resident #3, with fibromyalgia, gastroenteritis, and a UTI, also had an incomplete assessment. Resident #6, who had benign prostatic hyperplasia, peripheral vascular disease, and dementia, had their assessment signed late as well. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing and signing the MDS assessments. The Regional MDS Coordinator, who was an LVN, could not sign the assessments, and there was no clear process for ensuring timely completion. The Director of Nursing and the Administrator were not fully aware of who was responsible for tracking and signing the assessments, leading to delays and non-compliance with federal regulations.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the initial comprehensive assessments accurately reflected the status of two residents, leading to potential risks in their care. For Resident #4, the admission comprehensive assessment inaccurately coded her as having an indwelling catheter, despite documentation and observations indicating she did not have one. This error was identified through a review of her medical records and an interview with the Regional MDS Coordinator, who confirmed the mistake and noted that it would not have impacted her care since the catheter was not present. Resident #5's assessment inaccurately documented her fall history, failing to note a fracture related to a fall within the six months prior to her admission. This discrepancy was discovered through a review of her physician's progress notes and hospital discharge summary, which clearly indicated a fall resulting in a fracture. The Regional MDS Coordinator acknowledged the oversight and stated that the error did not impact Resident #5's care, as she was stable upon admission and received appropriate fall interventions. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clarity regarding responsibility for the accuracy of MDS assessments. The facility's policy mandates comprehensive and accurate assessments, with interdisciplinary responsibility for completion. However, the corporate company was primarily responsible for entering information into the MDS assessments, which may have contributed to the inaccuracies observed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. The care plans did not address the residents' full code status, fall risks, or specific interventions to prevent or mitigate injuries from falls. This deficiency was identified through interviews and record reviews, revealing that the care plans lacked essential information despite the residents having a history of falls and requiring assistance for transfers. Resident #1, who was cognitively intact and had a history of falls, did not have a care plan reflecting her full code status or specifying the number of staff required for transfers. Similarly, Resident #4, who was moderately cognitively impaired and had a history of falls, lacked a care plan addressing her full code status and fall risk. Resident #5, severely cognitively impaired and assessed as high fall risk, did not have her fall risk or history addressed in her care plan. Resident #6, moderately cognitively impaired with multiple falls, also lacked a care plan reflecting his full code status, ADL needs, and fall risk. Interviews with facility staff, including the LCSW, Regional MDS Coordinator, and DON, revealed inconsistencies in the care planning process. The LCSW acknowledged the omission of code status in care plans, while the Regional MDS Coordinator and DON discussed the interdisciplinary team's role in care planning. However, there was uncertainty about who was responsible for reviewing care plans for completion. The facility's policy required comprehensive care plans to be developed and implemented within specific timeframes, but these requirements were not met for the residents reviewed.
Failure to Implement Comprehensive Care Plans Leads to Multiple Falls
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which led to multiple falls and injuries. Resident #1, who was admitted with a broken neck from a fall at home, experienced several falls at the facility, including one that resulted in a subdural hemorrhage requiring hospitalization. Despite being identified as a high fall risk, Resident #1's care plan was incomplete, and no interventions were documented to prevent future falls. The facility's lack of a comprehensive care plan for Resident #1 contributed to the repeated falls and subsequent injury. Resident #4, who was assessed as a high fall risk, also did not have a comprehensive care plan in place. The resident experienced a fall in the bathroom, but no interventions were documented to prevent future falls. The facility's failure to develop a care plan for Resident #4 left the resident vulnerable to accidents and injuries. Similarly, Resident #3, who was identified as having a moderate risk for falls, did not have a comprehensive care plan, leaving the resident without documented interventions to mitigate fall risks. The facility's deficiency in developing and implementing care plans was exacerbated by staffing issues, including the absence of an MDS Coordinator and the DON's inability to fulfill her duties due to working as a floor nurse. The lack of comprehensive care plans meant that staff were not adequately informed about residents' needs and interventions, leading to a failure in providing appropriate care and preventing falls.
Inadequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with a significant history of falls. The resident, who was admitted with multiple diagnoses including parkinsonism and progressive supranuclear ophthalmoplegia, experienced five documented falls during their stay. Despite being identified as a high fall risk, the resident did not have a comprehensive care plan in place, and interventions to prevent future falls were not documented after each incident. The resident's falls were often unwitnessed, and staff interviews revealed a lack of awareness and training regarding fall prevention measures. The facility's electronic record system did not have updated care plans or Kardexes, leaving staff without clear guidance on interventions. The resident's impulsivity and nocturnal activity were known, yet supervision was inconsistent, and the facility lacked a visual identification system for fall risks. Interviews with staff, including the DON and CNAs, highlighted systemic issues such as understaffing, lack of training, and inadequate communication of fall risk interventions. The facility was newly opened, and the DON was overwhelmed with duties, impacting her ability to implement and monitor fall prevention strategies. The resident's family was aware of the fall risk and had expressed concerns, but the facility did not have a structured fall prevention program in place.
Incomplete MDS Assessments Due to Staffing and Oversight Issues
Penalty
Summary
The facility failed to ensure that a registered nurse signed and certified the completion of the Minimum Data Set (MDS) assessments for two residents. Resident #1's admission MDS assessment was not completed, with the assessment being seven days overdue. The assessment was signed by a social worker and a Corporate MDS Licensed Vocational Nurse (LVN), but lacked the required RN signature, and the Care Area Assessments (CAAs) were left blank. Similarly, Resident #3's admission MDS assessment was twelve days overdue, also signed by a social worker and the Corporate MDS LVN, but without an RN signature and incomplete CAAs. The facility's staffing issues contributed to these deficiencies. The Director of Nursing (DON) was working night shifts due to staffing shortages and was unable to perform her duties, including overseeing MDS assessments. The facility lacked an Assistant Director of Nursing (ADON) and an MDS Coordinator, relying instead on corporate staff to handle MDS assessments remotely. The Corporate MDS nurse, who was an LVN, was responsible for completing the assessments but was overwhelmed with responsibilities across multiple facilities and unable to keep up with the workload. Interviews with facility and corporate staff revealed a lack of communication and oversight regarding MDS assessments. The Corporate MDS nurse worked remotely and had limited communication with the facility's DON. The Director of Clinical Operations at the corporate level was unaware of the need for RN signatures on MDS assessments and had not communicated directly with the DON. This lack of coordination and oversight led to the incomplete and uncertified MDS assessments for the residents in question.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was scheduled to receive oxycodone prior to rehabilitation services. The resident, who had undergone a right knee replacement, was prescribed oxycodone/acetaminophen to manage pain, particularly before therapy sessions. However, on the day in question, the medication was not administered as there was no oxycodone available at the facility. The resident expressed anxiety about participating in therapy without the medication, although she reported no pain at the time of the interview. The facility's LVN, who was new to the facility, confirmed that the medication was not available and was unsure why it had not been reordered. The facility had an emergency kit containing oxycodone, but the LVN did not consider using it. The resident's family was expected to bring the medication from home, but it would not arrive in time for the therapy session. The facility's DON acknowledged that the facility should maintain a seven-day supply of medications and that there were technical difficulties with the new pharmacy system. The facility's policy required accurate acquiring, receiving, dispensing, and administering of medications, but these procedures were not followed, resulting in the resident not receiving her scheduled pain medication.
Lack of Qualified Dietary Management
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to manage the food and nutrition services, as required by regulations. Specifically, the facility did not have a certified Dietary Manager or a Registered Dietician to serve as the Director of Food and Nutrition Services. This deficiency was identified during a review of the staff roster, which revealed that the facility had three dietary staff members but lacked a qualified individual to oversee the dietary department. Interviews conducted with the Director of Nursing (DON), the Administrator, and dietary staff confirmed the absence of a Dietary Manager. The Administrator acknowledged that the facility had not had a Dietary Manager since its opening and that no one was currently covering the role. Although a dietary staff member, [NAME] F, was considering the position, she had not yet accepted it, nor was she enrolled in the necessary training or classes to qualify for the role. [NAME] F was involved in some duties such as ordering supplies and attending meetings but lacked the training and experience required for dietary assessments and management. Additionally, the Registered Dietician associated with the facility was not an employee and provided services remotely without in-person visits or oversight of the kitchen operations. The facility's policy required the employment of a qualified dietitian or a designated director of food and nutrition services with specific qualifications, which were not met. This lack of qualified oversight in the dietary department could potentially place residents at risk of foodborne illness and inadequate nutrition.
Failure to Hire Onsite MDS Coordinator Leads to Incomplete Assessments
Penalty
Summary
The facility failed to hire an onsite MDS Coordinator, which resulted in incomplete and unverified MDS assessments and care plans for residents. The facility relied on a Corporate MDS nurse to complete these assessments remotely, but this nurse was unavailable and unable to keep up with the workload due to managing multiple facilities. Consequently, no MDS assessments were transmitted, and comprehensive care plans were not completed for the residents. The facility was newly licensed and had multiple staff vacancies, including the absence of an Assistant Director of Nursing (ADON) and a Human Resources (HR) Director. The Director of Nursing (DON) was working night shifts due to staffing shortages and was unable to perform her regular duties, including oversight of MDS assessments. The Corporate MDS nurse, who was responsible for completing the assessments, was not on-site and had not communicated effectively with the facility staff, leading to a lack of completed care plans. Interviews with various staff members, including the Administrator, Corporate HR, and Corporate LNFA, revealed that the facility was aware of the staffing issues and the lack of MDS assessments being transmitted. The Administrator expressed that hiring decisions were controlled by corporate, and the Corporate LNFA stated that the facility had the authority to hire necessary staff. However, the facility had not yet hired an MDS Coordinator, and the Corporate HR Director only placed an ad for the position after the surveyor's entrance.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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