Avir At Killeen
Inspection history, citations, penalties and survey trends for this long-term care facility in Killeen, Texas.
- Location
- 5000 Thayer Dr , Killeen, Texas 76549
- CMS Provider Number
- 676438
- Inspections on file
- 54
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Avir At Killeen during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure proper storage and removal of medications when an expired Humalog insulin cartridge remained in a medication room refrigerator for a resident who was now receiving Ozempic, and a medication cart contained two loose pills and a cup with an unidentified pill. Interviews with the DON, ADON, and a med aide confirmed that nurses and med aides were responsible for discarding expired and discontinued medications in designated destruction bins and for auditing carts and medication rooms, but these processes did not prevent expired and unlabeled medications from being left in active storage areas.
Surveyors found that one medication cart and one medication room were not maintained according to medication storage standards. An expired Humalog cartridge remained in the medication room refrigerator for a resident who had been switched to Ozempic, and a medication cart contained two loose pills and a cup with an unidentified pill and no label. A cognitively intact resident with multiple chronic conditions reported receiving her medications and now taking Ozempic. The DON, ADON, and a med aide stated that nurses and med aides were responsible for discarding expired and discontinued medications in designated destruction bins and that narcotics were handled separately with the pharmacy consultant, but they could not explain why the expired insulin and unlabeled pills were still present.
A cognitively intact resident with multiple chronic conditions reported that a former roommate had slapped her on the thigh after a dispute over belongings. The resident stated she informed several CNAs and a family member shortly after the incident and later specifically told one CNA about the prior assault while receiving care. That CNA did not ask for details or timing and did not report the allegation to the abuse coordinator or administration, assuming it was a past event already reported and noting the resident did not appear upset. Facility policy required all suspicions or allegations of abuse or neglect to be reported immediately to the administrator/abuse coordinator within defined time frames, but this did not occur, resulting in a deficiency for failure to timely report an alleged abuse incident.
A resident with multiple chronic conditions developed a persistent rash related to incontinence and hygiene issues. Despite new medical orders for treatment, the care plan was not updated in a timely manner to include all prescribed interventions or measurable objectives. Staff interviews and record reviews confirmed that the care plan did not accurately reflect the resident's current needs until after the deficiency was identified.
A resident who required staff assistance for ADLs did not consistently receive showers according to the facility's established schedule. Documentation and interviews revealed that showers were sometimes missed or provided at unscheduled times, and the resident occasionally received bed baths instead, particularly when there were issues such as cold water. Staff acknowledged the importance of regular bathing for hygiene and skin integrity, and the facility's policy required such care for dependent individuals.
A resident with moderate cognitive impairment and Alzheimer's disease was financially exploited when a staff member gained access to her bank account and made unauthorized withdrawals totaling over $10,000. The staff member convinced the resident to add her to the account under the guise of providing financial assistance, then withdrew funds without consent. The incident was discovered after another staff member overheard a conversation and reported it to administration.
Two residents with care plans requiring supervision were allowed to smoke without staff present and kept cigarettes and lighters in their rooms, in violation of facility policy. Both residents were cognitively intact but had medical conditions such as muscle weakness and lack of coordination. Staff interviews confirmed that supervision and secure storage of smoking materials were required but not consistently enforced.
A resident with hemiplegia and multiple comorbidities was found in bed with the call light on the floor and out of reach. The resident, who was alert and required assistance for daily living, was unable to call for help due to the call light's placement. Staff confirmed the call light was not accessible and acknowledged the safety concern, in violation of facility policy requiring call systems to be within reach.
A resident with multiple chronic conditions and an indwelling urinary catheter was found with the catheter bag resting on the floor, contrary to facility policy and infection control standards. Staff interviews confirmed awareness of the infection risk, and record review showed the care plan and policy required catheter bags to be kept off the floor.
A facility area contained accident hazards and lacked sufficient staff supervision to prevent accidents, as observed by surveyors during their review of the environment and facility practices.
Three residents requiring oxygen therapy and nebulizer treatments did not have their respiratory equipment changed and documented as ordered, with observations revealing dirty equipment and missing documentation in the EHR. Staff interviews indicated inconsistent practices and uncertainty about responsibilities, while the facility's policy required weekly changes and documentation by nursing staff.
A resident with limited English proficiency and intact cognition was unable to communicate effectively with non-Spanish speaking staff, as the communication board provided was not useful and there were no Spanish-speaking staff available during certain shifts. Staff interviews confirmed ongoing communication barriers, and the facility lacked a specific policy for non-English speaking residents, resulting in unmet communication needs.
A staff member left a facility laptop open and unattended on a medication cart in a hallway, displaying confidential resident medical information. Multiple staff, including a medication aide, RN, DON, and Administrator, confirmed that this action violated HIPAA regulations and facility policy by making sensitive information accessible to unauthorized individuals.
A resident with diabetes and cognitive communication deficits did not receive prescribed doses of Acidophilus on multiple occasions, as confirmed by missing entries in the MAR and staff interviews. Facility policy required timely administration and documentation of medications, but these were not followed, resulting in the resident not receiving the supplement as ordered.
A resident with a history of skin conditions and impaired mobility developed a painful rash under her abdominal fold, which was not assessed or treated in a timely manner by the facility. Despite the resident's complaints and visible symptoms, the facility failed to notify the WCN or implement treatment orders until several weeks later, contrary to their policy on pressure injury prevention.
The facility failed to provide scheduled showers to three residents, leading to poor hygiene and dissatisfaction. A resident with hemiplegia and moderate cognitive impairment received only seven showers in a month, while another with severe cognitive impairment received five. A third resident reported going weeks without a shower, resorting to sponge baths. The DON expected showers thrice weekly, but no ADL policy was provided.
A resident with a non-pressure wound was not provided with proper infection control measures during care. A CNA failed to wear an isolation gown and did not perform hand hygiene after glove removal, while an LVN did not set up a clean field for wound care and used soiled gloves for multiple tasks. Both staff members placed soiled items in an unlined trash can, and the LVN cited the absence of a sanitizer machine as a reason for not performing hand hygiene.
A CNA in a LTC facility failed to perform proper perineal care during a disposable underwear change for a resident with incontinence. The CNA did not follow the facility's policy, which requires washing the perineal area from front to back, and only wiped the resident when soiled with fecal matter. The incident was reported by the resident's representative, and the facility's DON initiated an investigation. The resident was assessed with no injuries noted, and the CNA admitted to not following the procedure.
A resident with a history of cerebral infarction and spastic hemiplegia did not receive scheduled showers and assistance with personal hygiene, leading to deficiencies in care. Despite being scheduled for showers three times a week, the resident reported receiving only five showers and one bed bath over 60 days. Observations confirmed the resident had not been changed into fresh clothing for three days and had dirty dentures and fingernails. Facility documentation and monitoring were inadequate, and staff interviews revealed inconsistencies in understanding and implementing ADL care policies.
A resident with severe cognitive impairment alleged sexual assault by two men. Despite initial assessments showing no signs of assault, a subsequent exam revealed the presence of semen. The facility's investigation did not identify any perpetrators, and the cameras in the area did not record footage. The facility failed to protect the resident from sexual abuse and lacked effective monitoring and investigation procedures.
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, with expired food products found in dry storage and the refrigerator, and food boxes stored on the floor in the walk-in freezer. Interviews confirmed that these practices could lead to contamination and foodborne illness.
The facility failed to address and follow up on grievances raised during Resident Council meetings, including issues with staff behavior, call lights, and food quality. Despite documenting these grievances, the Activity Director did not follow up or report back to the residents, leading to a deficiency in resident care and life quality.
A social worker verbally abused a resident by calling him 'stupid' in a moment of agitation, which was witnessed by the ADON and reported immediately. The resident, who had multiple diagnoses including Vascular Dementia and Anxiety, was reassured by staff and felt safe in the facility. The social worker was suspended during the investigation.
The facility failed to provide necessary grooming and personal care for six residents, leading to long, dirty nails, unkempt appearances, and potential infection risks. Staff interviews revealed inconsistencies in responsibilities and lack of training regarding nail care.
The facility failed to provide scheduled one-on-one activities for three residents with severe cognitive impairments and physical disabilities, as required by their care plans. This deficiency was identified through observations, interviews, and record reviews, revealing that the residents did not receive necessary in-room activities for January and February 2024, potentially impacting their mental and social well-being.
The facility failed to provide proper respiratory care for two residents by not dating, bagging, or replacing nebulizer and oxygen tubing every seven days, and not cleaning the air filter for an air concentrator. Observations and staff interviews confirmed that the equipment was not properly maintained, which could lead to respiratory infections.
The facility failed to ensure that residents' call lights were within reach, affecting five residents who needed assistance with activities of daily living. Observations revealed that call lights were on the floor or out of reach, posing potential risks for unmet needs and falls. Staff interviews confirmed the expectation for call lights to be accessible to residents.
The facility failed to complete a resident's admission assessment within the required 14-day period. The resident, admitted with multiple complex medical conditions, had an incomplete MDS assessment, and staff interviews revealed confusion about responsibility for Medicaid MDS assessments.
The facility failed to develop a comprehensive care plan within seven days after the required comprehensive assessment for a resident with multiple diagnoses. Interviews revealed that the care plan was expected to be completed within 21 days of admission, but it was not completed on time, potentially leading to improper care methods.
A resident with severe cognitive impairment and a history of falls was moved by the Director of Therapy without necessary assessments after a fall, despite instructions from an LVN to wait. This action was against the facility's protocol, which required a nurse to complete pain assessments, vital signs, and other evaluations before moving the resident.
The facility failed to ensure that all drugs and biologicals were labeled and not expired in the Pod 2 medication storage room, medication cart, and nurse treatment cart. Staff were unaware of policies regarding the checking and removal of expired medications, and the ADON confirmed that expired medications could be ineffective in treating residents' conditions.
The facility failed to make the most recent survey results easily accessible to residents, with the survey book not located in common areas and unclear signage. Staff were unaware of the book's location, and residents expressed they did not know how to access the survey results.
Improper Medication Storage and Failure to Remove Expired Drugs
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to improper medication storage and failure to remove expired medications. During an observation of a medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 and dated 12/26/2024 for a specific resident was found still stored. The DON later stated that this resident no longer used Humalog and was currently taking Ozempic instead. The facility’s policy on Medication Labeling and Storage, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. Additional observations on a medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill. The DON, when interviewed, stated she did not know what the pill was or why it was left there and discarded the medications. The DON also stated that staff should not keep medication in the cart in a cup with no label or have loose pills in the cart, and that medication carts should be clutter-free with expired medications removed. The facility’s policy required medications and biologicals to be stored in locked compartments under proper conditions, with nursing staff responsible for maintaining safe and sanitary storage and preparation areas. Interviews with the ADON, DON, and a med aide showed that responsibility for discarding expired medications and auditing medication carts and rooms was assigned to nurses and medication aides. The ADON stated that expired medications and medications for discharged residents were to be discarded in a designated destruction box in the medication rooms, and that narcotics were stored in a lock box in the DON’s office until destroyed with the pharmacy consultant. The DON and med aide each confirmed that nurses and med aides were responsible for throwing away expired medications and that everyone should receive their medications as ordered. Despite these stated expectations and procedures, the presence of an expired Humalog cartridge in the refrigerator and unidentified loose and cup-held pills in the medication cart demonstrated that the facility did not ensure all drugs and biologicals were stored properly and that expired or unidentified medications were removed as required.
Improper Storage and Failure to Discard Expired and Unidentified Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of four medication carts and one of two medication rooms. During an observation of the medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 was found for a resident who was no longer using that medication and was currently taking Ozempic instead. The facility’s own policy, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that medications be stored in a clean, safe, and sanitary manner. Record review showed the involved resident was an older female with multiple diagnoses, including major depressive disorder, mixed hyperlipidemia, unspecified polyneuropathy, gout, and an unspecified muscle disorder. Her MDS indicated she was cognitively intact with a BIMS score of 14 and required partial to moderate assistance with several ADLs, while being dependent on staff for showers. She reported receiving her medications and not missing doses, and stated she was now taking Ozempic instead of her prior diabetic medication, though she did not recall the previous medication’s name. Additional observations on the medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill, with no label or resident identification. The DON, who did not know what the pill was or why it was left there, discarded the medications. In interviews, the ADON, DON, and a med aide each stated that nurses and medication aides were responsible for discarding expired medications into designated destruction bins, and that narcotics were handled separately with the pharmacy consultant. They acknowledged that medications should not be left loose or in unlabeled cups in the cart and that expired medications should have been discarded, but they were unable to explain why the unknown pill and loose pills were present in the cart or why the expired Humalog remained in the refrigerator.
Failure to Timely Report Resident’s Allegation of Abuse to Abuse Coordinator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours, to the administrator/abuse coordinator and proper authorities. A cognitively intact female resident with a history of type 2 diabetes, mild protein-calorie malnutrition, hypertension, prior stroke with upper limb monoplegia, muscle weakness, unsteadiness, and lack of coordination reported that her former roommate had slapped her on the thigh several weeks earlier after a dispute over food items. The resident stated she told multiple CNAs within a few days of the incident, as well as her family member the day after it occurred, but she could not recall the staff members’ names. She later specifically recalled informing one CNA (CNA A) about the incident several days after it happened. Record review showed that during a later counseling session, the licensed professional counselor (LPC) learned of the allegation and relayed it to the social worker (SW), who then reported it to the administrator/abuse coordinator. The facility’s investigation documented that the resident had previously told CNA A on an earlier date that she did not like her roommate because the roommate had hit her in the past. During interview, CNA A confirmed that, while providing care a few weeks prior, the resident reported that her roommate had hit her at some point in the past. CNA A did not ask when the incident occurred or obtain further details, and she did not report the allegation to the abuse coordinator or other facility leadership at that time. CNA A stated she took the report lightly because the resident was talking about other topics and laughing, and because the resident said she had already told other CNAs when it happened. CNA A acknowledged that she recognized the administrator as the abuse coordinator but chose not to report the allegation, believing it was a past event and that the resident did not appear upset. The facility’s written policy on abuse, neglect, exploitation, and misappropriation required that any suspicion of abuse or related violations be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse resulting in serious bodily injury and within 24 hours for allegations that do not involve abuse or do not result in serious bodily injury. The failure of CNA A to report the resident’s allegation in accordance with this policy led to the cited deficiency for not ensuring that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours.
Failure to Update and Implement Comprehensive Care Plan for Resident with Rash and Incontinence Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including COPD, hypertension, dementia, diabetes, and mobility difficulties. Despite the resident being cognitively intact, the care plan was not updated in a timely manner after new orders were received from a nurse practitioner regarding a rash. The care plan did not initially include all prescribed treatments, such as oral doxycycline and fluconazole, and lacked measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Interviews and observations revealed that the resident experienced a persistent rash under the breast and torso, which was associated with incontinence and hygiene challenges. Staff reported that the resident often refused to wear briefs or use the bathroom, resulting in prolonged exposure to moisture and contributing to the skin condition. Multiple staff members, including CNAs, LVNs, and the DON, noted that the care plan was not promptly updated to reflect the new interventions and that this could hinder the delivery of appropriate care. Record reviews and staff interviews confirmed that the care plan was only revised after questions were raised, and prior to that, it did not accurately reflect the resident's current needs or the interventions required. The facility's policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in this case, leading to a gap in care planning and implementation for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing, received showers as scheduled. According to the electronic shower schedule, the resident was to receive showers on Tuesdays, Thursdays, and Saturdays during the 2pm-10pm shift. However, record review showed inconsistencies in the dates and times showers were provided, with some showers occurring outside the scheduled days and times, and gaps in adherence to the established schedule. The resident, who was cognitively intact and required partial to moderate assistance with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene, was observed to be clean and without foul odors during the survey. She reported that her showers depended on which staff member was assigned and that she sometimes received bed baths instead, particularly when there were issues such as cold water. The resident stated she refused bed baths with cold water and would escalate concerns to facility staff or the Ombudsman if needed. Staff interviews confirmed that the resident was vocal about her care preferences and that missed showers could lead to hygiene and skin issues. Facility staff, including the DON, CNA, Med Aide, LVN, and ADM, acknowledged the importance of regular showers for residents to prevent skin breakdown and maintain hygiene. They also confirmed that the resident did not typically refuse showers and was proactive in communicating her needs. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, but the observed inconsistencies in shower provision indicated a failure to fully meet these requirements for the resident in question.
Failure to Prevent Misappropriation of Resident Funds by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by allowing an assistant (AC) to access the resident's bank account, resulting in four unauthorized transactions totaling $10,250. The resident, an elderly female with a history of cerebral infarction and Alzheimer's disease, had moderate cognitive impairment as indicated by a BIMS score of 12. The resident reported that the assistant convinced her to add the assistant to her bank account under the pretense of helping with finances, but subsequently withdrew funds without the resident's knowledge or consent. Only a portion of the funds was returned to the resident. Staff interviews revealed that a certified medication aide overheard the assistant instructing the resident not to disclose information about the money and reported this to the administrator. The administrator confirmed that the assistant's name appeared on the resident's bank account and that multiple large withdrawals were made. The facility's policy required protection of residents from misappropriation and mandated background checks, but the misappropriation occurred without the facility's awareness until after the funds were taken.
Failure to Enforce Smoking Supervision Policy
Penalty
Summary
The facility failed to follow its established smoking policy for two residents who were reviewed for smoking. Both residents were observed or reported to have smoked without staff supervision and to have kept cigarettes and lighters in their rooms, contrary to facility policy. Specifically, one resident was observed smoking in the designated area without staff present, and she stated that she kept her smoking materials in her purse in her room and smoked whenever she wanted. The other resident also reported keeping cigarettes and a lighter in her room and smoking at her discretion, noting that staff were not always present during smoking times. Both residents had care plans indicating the need for staff supervision or adaptations when using tobacco products. Medical records showed that both residents were cognitively intact but had diagnoses including muscle weakness, lack of coordination, and other conditions that could increase their risk during unsupervised smoking. Despite these care plans and diagnoses, the facility did not ensure that staff were present during smoking or that smoking materials were secured as required by policy. Interviews with facility staff, including the HRD, CN, and ADM, confirmed that the policy required staff supervision during smoking and that residents were not to keep smoking materials in their rooms. Staff acknowledged that unsupervised smoking could pose safety hazards, but were unaware of any injuries or incidents resulting from these lapses. The facility's written smoking policy also specified that residents requiring monitoring must be under direct supervision at all times while smoking and may not keep smoking articles except under supervision.
Call Light Not Accessible to Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when a male resident with hemiplegia, chronic kidney disease, heart failure, obstructive uropathy, and atrial fibrillation was found in bed with his call light on the floor behind the head of his bed, out of his reach. The resident, who was alert and had no cognitive impairment, stated he was unaware the call light was on the floor and could not reach it due to his partial paralysis. He expressed that he required the call light to request staff assistance for activities of daily living and would not be able to call for help if needed. The resident did not know how the call light ended up on the floor and confirmed he did not place it there. Staff interviews confirmed that the call light was not within the resident's reach at the time of observation, and staff acknowledged that this posed a safety concern, as the resident would not be able to summon help and could potentially fall if attempting to retrieve it. The facility's policies require that residents have access to a call system from their bed and guarantee residents' rights to a dignified existence and the ability to communicate their needs. The failure to ensure the call light was accessible was observed and confirmed by multiple staff members, including nursing and administrative personnel.
Catheter Bag Found on Floor Violates Infection Control Policy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with an indwelling urinary catheter. On the date of observation, the resident’s catheter bag was found hanging off the side bed rail with the bottom of the bag resting on the floor. The resident, who had diagnoses including hemiplegia, chronic kidney disease, heart failure, obstructive uropathy, and atrial fibrillation, was unable to see the catheter bag from his position and was unaware it was on the floor. Multiple staff interviews confirmed that the catheter bag being on the floor was an infection control issue, as it could expose the bag and tubing to bacteria and create a risk for infection, especially given the resident’s immunocompromised status. Record review showed that the resident’s care plan included monitoring for signs and symptoms of urinary tract infection and that the facility’s policy required catheter bags and tubing to be kept off the floor. Staff, including RNs, LVNs, and the administrator, acknowledged during interviews that the catheter bag on the floor was a violation of infection control practices and could lead to contamination. The facility’s own policy, updated in July 2024, specifically stated that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated urinary tract infections.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight by staff to mitigate these risks. The deficiency was identified based on direct observation and review of facility practices related to accident prevention.
Failure to Document and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy and nebulizer treatments. Specifically, the facility did not ensure that nebulizer masks and oxygen cannulas were changed and documented according to physician orders and facility policy. Observations revealed that one resident's nasal cannula appeared dirty and there was no documentation in the electronic health record (EHR) indicating when it had last been changed. Interviews with the resident and her roommate provided conflicting accounts of when the cannula was last replaced, and staff interviews confirmed that the process for changing and documenting respiratory equipment was inconsistent. Record reviews for the three residents showed active orders for regular changing of oxygen and nebulizer tubing, masks, and cannulas, with specific instructions for weekly changes and documentation in the EHR. However, there was no evidence in the records that these changes were consistently performed or documented. Staff interviews revealed a lack of clarity regarding responsibility and routine for changing respiratory equipment, with some staff stating it should be done weekly, typically on Sundays, and others unsure of the exact process. The facility was also in the process of transitioning to a new EHR system, which contributed to gaps in documentation. The facility's own policy required weekly changing and documentation of oxygen and nebulizer tubing and masks by the nursing department. Despite this, the required documentation was missing, and direct observation confirmed that at least one resident was using respiratory equipment that had not been changed as required. This failure to follow established protocols and document care placed residents at risk for infection, as noted by staff during interviews.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure the right to a dignified existence, self-determination, and effective communication for a resident with limited English proficiency. The resident, a Spanish-speaking male with diagnoses including diabetes mellitus, diabetic arthropathy, and a cognitive communication deficit, was unable to communicate effectively with staff who did not speak Spanish. The care plan identified the resident's communication needs and included interventions such as the use of visual cues, gestures, flash cards, and a communication board, as well as contacting family or friends for assistance. However, observations revealed that these interventions were not effectively implemented, as the communication board was not accessible or useful to the resident, and staff frequently relied on ad hoc methods such as sign language or seeking out Spanish-speaking staff when available. Multiple staff interviews confirmed that most staff, including those on evening and night shifts, did not speak Spanish and found the communication board ineffective. Staff reported difficulty in assessing the resident's needs, including pain levels, and often depended on non-verbal cues or attempted to find a Spanish-speaking colleague, which was not always possible. The Director of Rehabilitation, who was a Spanish speaker, acknowledged concerns about the lack of Spanish-speaking staff during certain shifts and the resulting communication barriers. The Director of Nursing and Administrator also recognized the importance of communication but indicated that the primary tools available were the communication board and the ability to call a Spanish-speaking staff member by phone, which was not consistently utilized. Review of facility policy confirmed the right of residents to communication and access to services, but no specific policy for non-English speaking residents was provided when requested. Observations and interviews demonstrated that the resident was unable to reliably communicate his needs or understand staff instructions, and the interventions outlined in the care plan were not effectively supporting his communication needs.
Unattended Laptop with Resident Information Left Accessible
Penalty
Summary
A staff member left a facility laptop open and unattended on a medication cart in a hallway, with confidential resident medical information visible on the screen. This occurred while the medication aide was in a resident's room, leaving the laptop accessible to anyone passing by. The observation was confirmed on the specified date, and interviews with multiple staff members—including medication aides, an RN, the DON, and the Administrator—acknowledged that leaving the laptop open and unattended constitutes a violation of HIPAA regulations and facility policy regarding the security of resident information. Staff interviewed stated that leaving the laptop open could allow unauthorized individuals to view or alter resident information. All interviewed staff, including the DON and Administrator, confirmed awareness of the policy and acknowledged that such an action is a breach of confidentiality and resident rights. The report did not mention any specific residents affected or provide details about their medical history or condition at the time of the incident.
Failure to Administer and Document Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring that Acidophilus, a prescribed supplement, was administered as ordered on multiple occasions. Specifically, the medication was not given on several documented dates and times, as evidenced by gaps in the Medication Administration Record (MAR). Interviews with staff confirmed that if a medication is not documented as given in the MAR, it is considered not administered. The staff responsible for administering and documenting the medication did not record its administration, and attempts to interview the medication aide responsible were unsuccessful. The resident involved was an adult male with a history of diabetes mellitus with diabetic arthropathy, cognitive communication deficit, and a need for assistance with personal care. His care plan included interventions for pain management and required medications to be administered as ordered. The facility's policy required medications to be administered and documented in a timely manner, with oversight by nursing leadership. Review of the MAR and staff interviews confirmed that the required documentation and administration did not occur for the specified dates and times.
Failure to Timely Address Resident's Skin Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who developed a rash under her abdominal fold, causing her significant pain. The resident, who was moderately cognitively impaired and at risk for pressure ulcers due to impaired mobility, reported that a CNA had torn off her brief too quickly, causing the Velcro to scrape her skin. Despite the resident's complaints of pain and the visible rash, the facility did not assess or implement treatment orders in a timely manner. The resident's skin assessment conducted on 11/19/24 by LVN A and the ADON did not note any new skin issues, and no treatment orders were in place until 11/22/24, when Nystatin powder was applied. The resident and a CNA reported that the rash had been present for at least two weeks, and the resident's RP confirmed that the redness had been present for at least a week. The WCN and WCD were not notified of the skin issue, contrary to the facility's procedure, which required nurses to report new skin integrity issues. Interviews with facility staff revealed a lack of communication and follow-through in addressing the resident's skin condition. The DON acknowledged that the redness should have been reported to the WCN for assessment and potential treatment orders. The facility's policy on pressure injury prevention emphasized the importance of regular skin assessments and timely reporting of changes, which were not adhered to in this case.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good hygiene. Specifically, three residents did not receive showers in compliance with their scheduled shower times. Resident #3, a female with hemiplegia and moderate cognitive impairment, was observed with messy and greasy hair, oily face, and crusty eyes. She reported going long periods without showers, which made her feel sad. Her records indicated she received only seven showers over a month, despite requiring extensive assistance with ADLs. Resident #4, a male with severe cognitive impairment, was observed with a greasy face and stubble, and he reported not receiving regular showers, with the last one being a week prior. His records showed he received only five showers in a month. Resident #5, a female with moderate cognitive impairment, reported going 2-3 weeks without a shower and resorted to sponge baths due to feeling dirty. Her records indicated she received only one shower in nearly a month. The Director of Nursing (DON) stated that residents should receive showers at least three times a week, and any refusals should be documented. However, a policy on ADLs was not provided before the survey exit.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in protocol during the care of a resident. The resident, a female with a history of dermatitis, type II diabetes, obesity, cellulitis, and muscle wasting, was on enhanced barrier precautions due to a non-pressure wound on her right posterior thigh. During an observation, a CNA did not wear an isolation gown while performing incontinent care for the resident, and used soiled gloves to touch various surfaces, including the light switch and privacy curtains, without changing gloves or performing hand hygiene. The CNA also placed soiled wipes in an unlined trash can and failed to perform hand hygiene after removing gloves. An LVN, who was new to the facility, also failed to adhere to infection control protocols. The LVN did not set up a clean field for wound care supplies, placed soiled dressings in an unlined trash can, and did not change gloves or perform hand hygiene between tasks. The LVN applied wound care products with soiled gloves and contaminated the gloves further by reaching into her pocket. Additionally, the LVN did not perform hand hygiene after glove changes, citing the absence of a sanitizer machine in the room as the reason. Interviews with the CNA and LVN revealed a lack of adherence to the facility's infection control policies, including the use of personal protective equipment and hand hygiene practices. The Director of Nursing confirmed that the facility's policies require gloves and gowns to be worn during wound care for residents on enhanced barrier precautions, and that hand hygiene should be performed after glove removal or when gloves are soiled. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, leading to potential infection control issues.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that a certified nurse assistant (CNA) had the appropriate competencies and skill sets to provide proper nursing care, specifically in performing perineal care during a disposable underwear change. This deficiency was identified for one of the four CNAs reviewed for competent nursing care. The incident involved a resident who was cognitively intact and required assistance for activities of daily living due to incontinence of bowel and bladder. The CNA did not follow the facility's policy for perineal care, which requires washing the perineal area from front to back, and only wiped the resident when soiled with fecal matter. The deficiency was brought to the attention of the facility's administration by the resident's responsible representative, who reviewed camera footage showing the CNA's failure to perform proper perineal care. The Director of Nursing (DON) was informed, and an investigation was initiated. The resident was assessed by the Assistant Director of Nursing (ADON) and the Social Worker (SW), with no injuries or distress noted. The CNA admitted to not following the procedure and was subsequently counseled and removed from resident care for re-education.
Deficiency in Resident's ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, leading to deficiencies in personal hygiene, grooming, and oral care. The resident, a female with a history of cerebral infarction, depression, and spastic hemiplegia, required extensive assistance with personal hygiene and was dependent on staff for bathing. Despite being scheduled for showers three times a week, the resident reported receiving only five showers and one bed bath over a 60-day period. Observations confirmed that the resident had not been changed into fresh clothing for three days and had dirty dentures and fingernails. The facility's documentation and monitoring systems were inadequate, as evidenced by discrepancies in the Point of Care (POC) logs and shower sheets. The logs inaccurately reflected daily showers for a week, which the Director of Nursing (DON) found unlikely, indicating a lack of proper use of the POC system by aides. The DON, who had been employed for only a short time, acknowledged the need for a procedure to monitor compliance with ADLs and recognized the potential negative outcomes of failing to provide necessary care, such as infections and skin breakdown. Interviews with staff revealed a lack of consistent procedures and understanding of the facility's policies regarding ADL care. The DON and Administrator (ADM) both highlighted the importance of adhering to care plans and accommodating resident preferences, yet the ADM could not locate a specific policy on ADL care provision. Despite in-service training on nail care and personal hygiene, the facility's practices did not align with its policies, resulting in the resident's unmet needs and potential risks to her health and dignity.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was safe from sexual abuse. The resident, a 73-year-old female with severe cognitive impairment and multiple medical conditions, alleged that she was sexually assaulted by two men. Despite the facility's initial assessment and the hospital's initial report indicating no signs of sexual assault, a subsequent sexual assault exam revealed the presence of semen in the resident's brief and on and in her vagina. The incident was reported to the facility staff, who then contacted law enforcement and transferred the resident to the hospital for further evaluation. However, the facility's investigation did not identify any alleged perpetrators or witnesses, and the initial findings were deemed unfounded. The facility's records indicated that only female staff worked with the resident on the day of the incident, and the cameras in the area did not record footage, as they were set to stream live feed only. The facility's staff and the resident's family were interviewed, but no conclusive evidence was found to identify the perpetrators. The facility's failure to protect the resident from sexual abuse and the lack of effective monitoring and investigation procedures led to the deficiency.
Sanitation Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Observations revealed expired food products in the dry storage area, including 19 cans of evaporated milk and 6 containers of prune juice. Additionally, an open container of prune juice past its use-by date was found in the double door refrigerator. The walk-in freezer had two stacks of food product boxes on the floor, which is against the facility's policy. Interviews with the Dietary Manager, Dietitian, and Cook confirmed that expired food products should have been discarded and that food should not be stored on the floor, as these practices could lead to contamination and foodborne illness. The facility's Dietary Services Policy and Procedure Manual mandates that food should be stored off the floor and regularly checked for expiration dates, but these guidelines were not followed. The Dietary Manager admitted that the expired prune juice and evaporated milk should have been discarded and that dietary staff should regularly check dates and discard expired food products. The Dietitian and Cook also confirmed that expired food products should be removed and that failure to do so could result in food poisoning. The facility's policy does not specifically address the storage of food products or boxes on refrigerator/freezer floors, but it does require that all foods be covered, labeled, and dated. The facility's in-service record emphasizes the importance of checking for expired items and ensuring that all food is properly labeled and dated, but these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life. There was no documentation of the facility's effort to resolve grievances collected at Resident Council meetings on 11/07/2023, 12/12/2023, and 01/09/2024. This failure placed residents at risk of indignity and diminished quality of life. The Resident Council meetings documented various grievances, including issues with brief sizes, call lights not being answered, staff gossiping, and food quality, among others. However, there was no follow-up or resolution documented for these grievances. During a confidential group interview on 02/21/2024, residents expressed that they had been complaining about staff behavior, call lights not being answered, and food quality for the past 3 to 4 months without any resolution or feedback from the administration. The Activity Director confirmed that she attended all Resident Council meetings and documented the grievances but did not follow up or report back to the residents. The Administrator stated that the Activity Director was expected to give grievances to the appropriate Department Head and report the results back to the Resident Council, which was not done. The facility's policies on filing grievances and Resident Council support were not adhered to, leading to the deficiency.
Verbal Abuse by Social Worker
Penalty
Summary
The facility failed to ensure residents had the right to be free from abuse and neglect, specifically for one resident (Resident #68). The incident involved a social worker who verbally abused Resident #68 by calling him 'stupid' in a moment of agitation. This incident was witnessed by the ADON, who reported it immediately. The social worker was called back to the facility by administration to complete a medical records task and appeared agitated, which led to the verbal abuse. The resident was assessed and reassured by staff members following the incident, and the social worker was suspended during the investigation. The resident expressed that he felt safe in the facility and was not worried about the social worker. Resident #68 had a diagnosis of Vascular Dementia, Anxiety, Acute Congestive Heart Failure, Major Depressive Disorder, Irritable Bowel Syndrome, Acute Kidney Failure, and Chronic Atrial Fibrillation. His MDS assessment indicated normal cognitive abilities, and he was independent in performing all ADLs. The incident occurred near the front entrance and was observed by other residents and staff. The ADON stated that the social worker's behavior was unprofessional and that staff were aware that residents could have behaviors but were not to react negatively. Attempts to reach the social worker for an interview were unsuccessful.
Failure to Maintain Grooming and Personal Care
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal care for six residents. Resident #4 had long fingernails with brown debris, a curled toenail emitting a foul odor, and an unkempt beard and hair. Despite being observed on multiple occasions, his grooming issues were not addressed, leading to discomfort and potential infection risks. Resident #69 had long fingernails with debris, an unkempt beard, and soiled clothes. He was unaware of his grooming issues and agreed to have his nails trimmed when informed. The staff acknowledged the infection control and dignity concerns but failed to address them promptly. Resident #81 had a scruffy beard and long, dirty fingernails, which were not addressed in his care plan. Resident #74 had dry, flaky skin, dirty feet, and long toenails causing pain. Despite his complaints, his grooming needs were neglected, leading to potential infection risks. Resident #12 had long, jagged nails that caused self-inflicted scratches. She had repeatedly asked for nail trimming over two weeks, but her requests were ignored. Resident #240 had nails with blackish substance underneath, which was not cleaned despite her request. Interviews with staff revealed inconsistencies in responsibilities and lack of training regarding nail care. CNAs were responsible for trimming nails unless the resident had diabetes, in which case nurses were to arrange for nail care. However, there was no clear protocol or backup plan in place, especially in the absence of a social worker. The facility's policy emphasized maintaining residents' dignity and well-being, but the observed deficiencies indicated a failure to adhere to these standards.
Failure to Provide Scheduled One-on-One Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, as required by comprehensive assessments and care plans. Specifically, the facility did not ensure that one-on-one activities were provided according to the schedule for three residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that the residents did not receive the necessary in-room activities for the months of January and February 2024. Resident #6, a legally blind female with severe cognitive impairment and depression, did not receive any one-on-one activities or attend group activities during the specified period. Her care plan indicated a preference for in-room activities and a risk for mood instability. The Activity Director confirmed that Resident #6 did not receive the required visits and acknowledged the potential negative impact on her mental and social well-being. Similarly, Resident #36, who had severe cognitive impairment and multiple physical disabilities, did not receive any in-room or group activities. Her care plan also highlighted a preference for in-room activities and a risk for social isolation. The Activity Director admitted that Resident #36 did not receive the necessary activities and recognized the potential for increased depression and anxiety. Resident #37, with severe cognitive impairment and physical disabilities, also did not receive the required one-on-one activities or attend group activities. The Activity Director noted that Resident #37 would benefit from music and other in-room activities but did not receive them, potentially leading to boredom and cognitive decline.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice. For Resident #18, the facility did not date, bag, or replace the nebulizer tubing and mouthpiece every seven days. Observations revealed that the nebulizer mouthpiece was found on the floor and the oxygen tubing was undated and unbagged. Resident #18's care plan did not include any problem area for oxygen or nebulizer treatment, and there were no physician orders regarding the care of the nebulizer equipment. Staff interviews confirmed that the equipment was not properly maintained, which could lead to respiratory infections. For Resident #19, the facility failed to date and replace the oxygen tubing and mask every seven days, and the air filter for the air concentrator was not cleaned and was covered in debris. Observations showed that the oxygen tubing and humidifier bottle were undated, and the nebulizer mask was not bagged and displayed an outdated date. Resident #19 confirmed that she was continuously on oxygen and used the nebulizer, and staff interviews indicated that the equipment was not properly maintained. The hospice RN and other staff members acknowledged that the failure to change and date the equipment could result in respiratory infections. The facility's Respiratory Therapy - Prevention of Infection Policy outlined specific procedures for maintaining respiratory equipment, including changing oxygen tubing and nebulizer setups every seven days and cleaning air filters weekly. However, the facility did not adhere to these protocols, as evidenced by the undated and unbagged equipment for both residents. Staff interviews and record reviews further confirmed the lack of proper documentation and maintenance, highlighting a significant deficiency in the facility's respiratory care practices.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs, specifically regarding the accessibility of call lights. Observations revealed that five residents had their call lights out of reach, which could prevent them from calling for assistance when needed. For instance, Resident #54, who was totally dependent on staff for movement, had her call light on the floor and out of reach. Similarly, Resident #24, who required substantial assistance for transfers, also had his call light on the floor and out of reach while he was in bed with a wound vac attached to his left foot wound. Resident #52, who was legally blind and at risk for falls, was found in her bed with her call light on the floor, and she was unaware of its location. Resident #81, who was dependent on a manual wheelchair for indoor mobility, had his call light under his bed and out of reach. Lastly, Resident #69, who required substantial assistance for transfers and had a history of falls, was observed in his wheelchair with his call light on the floor. A CNA present in the room acknowledged that having call lights on the floor could create fall risks. Interviews with staff, including the ADON, Nurse Consultant, and Administrator, confirmed that the expectation was for call lights to be within reach of residents to prevent potential dangers such as falls or unmet needs. The facility's policy on answering call lights also emphasized the importance of ensuring call lights are within easy reach of residents when they are in bed or confined to a chair.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment of a resident's functional capacity. Specifically, the facility did not complete the admission assessment for a resident within the required 14-day period. The resident, a [AGE] year-old female, was admitted with multiple diagnoses including muscle wasting, lack of coordination, difficulty in walking, chronic kidney disease, pneumonia, fluid overload, metabolic encephalopathy, and essential hypertension. Despite these complex medical conditions, the admission MDS assessment was still in progress and had not been signed by an RN as of the survey date, which was beyond the required completion date. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of Medicaid MDS assessments. The Nurse Consultant and MDS Coordinator both indicated that someone from the corporate office was responsible for these assessments, but neither knew the person's name. The Administrator confirmed that the MDS assessment should have been completed within 14 days of admission and acknowledged that the resident might not receive appropriate care without a completed assessment. The facility's policy also mandates that the interdisciplinary assessment team conduct timely resident assessments within 14 days of admission to describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity.
Failure to Develop Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days after the comprehensive assessment was required to be completed for a resident. The resident, a [AGE] year-old female with multiple diagnoses including muscle wasting, lack of coordination, difficulty in walking, chronic kidney disease, pneumonia, fluid overload, metabolic encephalopathy, and essential hypertension, was admitted on [DATE]. The comprehensive care plan was not completed when reviewed on 02/24/2024, and the Admission MDS Assessment was still in progress as of 02/22/2024. Interviews with the Nurse Consultant, MDS Coordinator/LVN, and the Administrator revealed that the comprehensive care plan was expected to be completed within 21 days of admission, and the baseline care plan within 48 hours of admission. The Nurse Consultant acknowledged that without a completed MDS or comprehensive care plan, nursing staff might not know the appropriate care needed for the resident, potentially leading to improper care methods such as incorrect transfers. The facility's policy on care plans, revised in December 2016, stated that the comprehensive, person-centered care plan should be developed within seven days of the completion of the required comprehensive assessment (MDS).
Failure to Follow Protocol After Resident Fall
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not assess Resident #29 prior to moving her after she fell from her bed to the floor. This failure was observed when the Director of Therapy moved Resident #29 from the floor to the bed without conducting necessary assessments, despite being instructed by LVN B to wait until pain assessments, vital signs, and other evaluations were completed. The Director of Therapy ignored these instructions and proceeded to move the resident and perform range of motion exercises, which was against the facility's protocol for handling falls. Resident #29, an elderly female with a history of repeated falls, dizziness, muscle weakness, and other significant medical conditions, was found on the floor by her bed. Her medical records indicated severe cognitive impairment and a need for assistance with activities of daily living. Despite these conditions, the Director of Therapy moved her without waiting for the required assessments, potentially putting her at risk for further injury. Interviews with the staff, including LVN B, the Director of Therapy, the Nurse Consultant, and the Administrator, confirmed that the facility's protocol was not followed. The Director of Therapy admitted to making a mistake and acknowledged that she should have waited for the nurse to complete the necessary assessments. The facility's policy on falls required that a nurse assess and document vital signs, neurological status, and pain before moving a resident who had fallen, which was not adhered to in this case.
Expired Medications Found in Storage and Treatment Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions and expiration dates. This deficiency was observed in the Pod 2 medication storage room, medication cart, and nurse treatment cart. Specifically, five bottles of medications in the Pod 2 medication storage room, two medications in the Medication Aide cart, and one bottle of aspirin in the nurse treatment cart were found to be past their expiration dates. The staff, including an agency nurse and a medication aide, were unaware of the facility's policies regarding the checking and removal of expired medications. During interviews, the agency nurse and medication aide both indicated a lack of formal training and clarity on who was responsible for auditing the carts and storage rooms for expired medications. The Assistant Director of Nursing (ADON) confirmed that the nurses were primarily responsible for checking the medications, followed by the ADON. The ADON acknowledged that expired medications could potentially be ineffective in treating residents' conditions, posing a risk to their health.
Failure to Provide Accessible Survey Results to Residents
Penalty
Summary
The facility failed to place the most recent survey results in a location that was easily accessible to residents, as required by regulations. Observations on multiple occasions revealed that the survey book was not located in common areas frequented by residents, and there was no clear signage indicating its location. A small, hard-to-read sign was found on the receptionist's desk, which was too high for residents in wheelchairs to see. Interviews with the receptionist and the Activity Director confirmed that they were unaware of the survey book's location, and the receptionist stated that the book was sometimes kept behind the desk, making it inaccessible to residents, visitors, and families. In a group interview, nine residents expressed that they did not know where or how to access the survey results and were unaware that such a manual existed. They indicated a preference for being able to reach the manual themselves without having to ask for it. The Activity Director and the Administrator both acknowledged that residents have the right to view past surveys and that the current placement of the survey book and signage did not facilitate this. The facility's policy on Resident Rights, revised in January 2011, reflected that residents had the right to examine survey results, but this was not being effectively communicated or facilitated in practice.
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Citations used to create this checklist
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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