Avir At Lubbock
Inspection history, citations, penalties and survey trends for this long-term care facility in Lubbock, Texas.
- Location
- 4710 Slide Rd, Lubbock, Texas 79414
- CMS Provider Number
- 455940
- Inspections on file
- 55
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 7 (3 serious)
Citation history
Health deficiencies cited at Avir At Lubbock during CMS and state inspections, most recent first.
Two residents experienced a failure in protection from abuse when a resident with a known history of inappropriate sexual behaviors was not properly supervised or care planned upon admission, leading to an incident where she placed her hand inside another resident's panties. Staff were unaware of the resident's behavioral history, and there was a lapse in 1:1 supervision due to poor communication and shift change issues, resulting in the incident of sexual abuse.
A facility failed to implement and communicate abuse prevention policies, resulting in a resident with a known history of inappropriate sexual behavior being left unsupervised and able to inappropriately touch another resident. Staff did not review admission records thoroughly, were unaware of the resident's behavioral risks, and did not maintain required 1:1 supervision, leading to the incident.
Two residents with severe cognitive impairment and behavioral issues were not properly supervised, resulting in one resident with a history of sexual behaviors inappropriately touching another. Staff failed to maintain required 1:1 observation, were unaware of behavioral risks, and did not follow facility policies for supervision and communication, leading to an incident of sexual contact.
A resident with severe cognitive impairment and multiple medical conditions had a physician order for PRN hydrocodone-acetaminophen. Staff failed to perform the required narcotic count at shift change, resulting in the discovery of a missing blister pack of hydrocodone. Documentation in the EMR and on paper count sheets was inconsistent with the quantities of medication received and administered, and the facility was unable to account for a significant number of hydrocodone tablets.
Surveyors found that liquid Lorazepam requiring refrigeration was stored on medication carts instead of in a refrigerator, and at least one medication label was illegible, making it impossible to verify key information. Staff interviews confirmed awareness of storage and labeling requirements, but the deficiencies were not detected during routine audits, and some medications were received in improper condition.
A resident with severe cognitive and psychiatric conditions exhibited aggressive behaviors toward others on two occasions, but the care plan was not updated by the IDT to reflect new interventions or address these incidents. Although staff discussed the events and implemented one-to-one supervision, the formal care plan remained unchanged, and staff interviews revealed confusion about responsibility for care plan revisions.
Two residents with severe cognitive impairment received PRN Lorazepam orders that were not limited to 14 days, and the required physician rationale for extending these orders was not consistently documented. Medication administration records and care plans lacked proper documentation, and staff interviews revealed a lack of awareness and formal training regarding the 14-day stop date requirement for PRN psychotropic medications.
A facility failed to provide scheduled showers for three residents, leading to a deficiency in ADL care. One resident, cognitively intact, was denied a shower despite requesting it, while another, moderately impaired, was told it wasn't her shower day. A third resident was overlooked after moving rooms. Staff interviews revealed a lack of coordination and communication regarding the shower schedule, resulting in missed showers and inadequate documentation.
A facility failed to maintain a medication error rate below 5%, resulting in a 9.38% error rate due to three errors involving two residents. An LVN administered medications late and in incorrect dosages, affecting residents with conditions like neuropathy and metabolic encephalopathy. The errors were attributed to the LVN not verifying dosages and being asked to take over medication pass duties unexpectedly.
The facility failed to provide palatable and properly heated meals, affecting all food forms served. Residents reported dissatisfaction with cold and bland meals, confirmed by surveyors' observations. Staff interviews revealed a lack of training and oversight in maintaining food temperature from kitchen to service.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by staff not sanitizing equipment between resident use, neglecting hand hygiene during medication administration, and not adhering to enhanced barrier precautions during wound care. These actions were contrary to the facility's policies and could lead to cross-contamination and infection spread.
The facility failed to obtain consent for the administration of Lorazepam to two residents with severe cognitive impairments. Despite having protocols in place, the necessary consent forms were not signed by the residents or their legal representatives, leading to the administration of the medication without informed consent. Interviews with the DON and ADM highlighted the oversight in ensuring compliance with consent procedures.
The facility failed to limit PRN orders for psychotropic drugs to 14 days for two residents, leading to a deficiency in medication management. A resident with paranoid schizophrenia and another with dementia had PRN orders for Lorazepam without a stop date, extending beyond the 14-day limit. Interviews with the DON and ADM revealed a lack of awareness of these orders, despite the facility's policy requiring a 14-day limit unless otherwise documented by a physician.
The facility failed to properly store medications on two medication carts, resulting in loose pills being found. Staff responsible for the carts were unsure of the cause but acknowledged their responsibility for proper storage. The DON and ADM were unaware of the issue, despite regular training and audits. The facility's policy requires medications to be stored in labeled containers.
The facility failed to follow proper sanitization procedures for the puree machine in dietary services. The Dietary Manager did not allow the puree machine cannister to air dry between uses, leading to potential food contamination. Despite being trained on the correct procedure, the DM skipped this step due to time constraints, as confirmed by the Assistant Dietary Manager.
The facility failed to maintain an effective pest control program, resulting in rodent presence due to unrepaired holes. Residents reported mice-related issues, and the facility lacked a maintenance person for a period, delaying repairs. A new maintenance man was hired, and pest control visits increased to address the issue.
A resident with a history of cerebral infarction and reduced mobility was documented as receiving ADL care despite refusing it. The CNA admitted to documenting care before completion and not updating records for refusals. The DON and Administrator recognized the importance of accurate documentation, but no recent training was provided. The facility's policy requires accurate entries, but it was last revised in 2012.
The facility failed to provide routine showers for several residents, leading to frustration and dissatisfaction among them. Despite having various medical conditions, residents did not receive regular hygiene care, and shower sheets were left incomplete. Interviews revealed that residents had to repeatedly request showers, often without success, due to staff being too busy or uninterested. The facility's policy required assistance with hygiene, but the lack of adherence was evident in the documentation and resident grievances.
A resident's medical information was left exposed on a computer screen at a nurse's station, unattended by an LVN, allowing other residents to potentially view the information. The resident had multiple complex medical conditions and was moderately cognitively impaired. Interviews revealed that the LVN had not received recent privacy training, and the facility's policy on safeguarding electronic medical records was not followed.
A resident with dementia exhibited aggressive behavior towards other residents and staff, leading to incidents of abuse and neglect. The facility failed to document, investigate, or implement effective interventions to manage the resident's behavior. Allegations of abuse by nighttime staff were not properly addressed, and the administration was unaware of the incidents, resulting in a lack of preventive measures. This led to an Immediate Jeopardy situation identified by state surveyors.
The facility failed to implement its abuse prevention policies, resulting in unreported incidents involving a resident with severe cognitive impairment and aggressive behavior. The ADM did not report or investigate allegations of abuse and neglect, including staff abuse and resident-to-resident altercations. Staff interviews revealed a lack of communication and documentation, placing residents at risk.
The facility failed to report alleged abuse and neglect incidents involving a resident with dementia, including an allegation of abuse by a nighttime staff member and two resident-to-resident altercations. Staff members did not follow the facility's abuse policy, citing reasons such as the incident occurring over the weekend and assuming the allegations had already been reported. The ADM was unaware of the incidents and did not report them to HHSC.
A facility failed to investigate allegations of abuse and resident-to-resident altercations involving a resident with dementia. Despite reports of abuse by nighttime staff and altercations with two other residents, no investigations were conducted. Staff were aware of the incidents but did not report them, and the Administrator was unaware, preventing protective measures from being implemented.
A facility failed to update a care plan for a resident with dementia and aggressive behaviors, despite documented incidents of aggression towards staff and other residents. The care plan did not reflect the resident's worsening behaviors, and staff changes contributed to the oversight. The facility's administrator acknowledged the failure to revise the care plan in a timely manner, which was required by policy.
A resident with a history of pain and fractures did not receive prescribed Hydrocodone due to a locked narcotics box. Despite repeated requests, staff failed to provide alternative pain relief or notify a physician. The facility's emergency kit contained the medication, but staff were unaware and did not access it, leading to unmanaged pain for the resident.
A facility failed to implement its abuse prevention policies when a resident reported that another resident was being abused by staff. The ADM did not consider the report an allegation of abuse and did not document or investigate it further, relying instead on the DON's assessment that the screaming was normal behavior. CNA A reported the incident to the ADON, but no further action was taken. This failure to follow the facility's abuse policy could place residents at risk for abuse and neglect.
A facility failed to report allegations of abuse involving two residents within the required timeframe. A resident with dementia reported witnessing staff abuse another resident, but the administrator did not consider it an allegation of abuse and did not investigate further. Additionally, a CNA reported an accusation of abuse to the ADON, but it was not reported or investigated. The facility's failure to follow its abuse policy could lead to abuse occurring without being discovered or addressed.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA during a transfer, but the incident was not reported to the administration as required by the facility's abuse prevention policy. Despite being trained on reporting procedures, an LVN did not consider the report of rough handling as abuse because the term 'abuse' was not used. This failure to report prevented the facility from investigating the matter, highlighting a deficiency in the facility's abuse prevention measures.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA during a transfer, but the allegation was not reported within the required timeframe. A family member informed an LVN, who did not escalate the report to the Administrator or DON, leading to a delay in investigation. The facility's abuse prevention policy requires immediate reporting of such incidents, but this protocol was not followed.
A resident with Alzheimer's and other cognitive disorders exhibited behaviors of exposing himself and urinating on the floor, which were not addressed in his care plan. Despite staff awareness of these behaviors, they were not documented or reported to the DON for monitoring and intervention, contrary to facility policy.
The facility failed to maintain adequate staffing in the memory care unit, leading to unsupervised incidents involving two residents with severe cognitive impairments. A male resident exhibited inappropriate behaviors such as urinating on the floor, while a female resident displayed aggressive actions towards others. Interviews revealed that the unit was often left with only one staff member, contrary to the facility's policy requiring two staff members at all times.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two residents reviewed for abuse and neglect. Specifically, the facility did not ensure a safe environment free from sexual abuse when a resident with a known history of inappropriate sexual behaviors placed her hand inside another resident's panties. The Director of Nursing (DON) did not implement necessary interventions upon the admission of the resident with a history of sexual behaviors, despite being informed by an LVN that the resident was masturbating and had inappropriately touched the DON during assessment. The facility's staff, including the DON, were unaware of the resident's history of inappropriate sexual behaviors prior to admission, even though documentation from the previous facility included multiple incidents of such behavior. The incident occurred when the resident with a history of sexual behaviors was found with her hand inside another resident's panties in the latter's room. Staff interviews revealed that the resident who was touched was supposed to be on 1:1 observation due to prior aggressive behavior, but there was a lapse in supervision during a shift change, and the assigned staff for 1:1 observation did not arrive on time. Other staff members were unaware of the need for close supervision of the resident with a history of sexual behaviors, and there was confusion and lack of communication regarding the assignment and implementation of 1:1 observation. The care plans for both residents did not initially address the risk of inappropriate sexual behavior or the need for specific interventions to prevent such incidents. Record reviews and staff interviews further indicated that the facility's admission process failed to identify and communicate the high-risk behaviors of the newly admitted resident. Key staff members, including the social worker, MDS coordinator, and admission coordinator, did not review or were unaware of the resident's documented history of inappropriate sexual conduct. The lack of proper review and communication led to insufficient care planning and supervision, resulting in the incident of sexual abuse between residents. The facility's policies on abuse, neglect, and supervision were not effectively implemented or followed at the time of the incident.
Failure to Implement Abuse Prevention Policies Leads to Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not identify or address at admission a resident's history of inappropriate sexual behavior, which resulted in an incident where this resident placed her hand inside another resident's underwear. The staff did not review the admission documents thoroughly, missing multiple documented incidents of inappropriate sexual behavior from the transferring facility. Key staff members, including the DON, social worker, MDS coordinator, and admission coordinator, were unaware of the resident's behavioral history at the time of admission, and the care plan did not initially reflect the need for interventions to address these behaviors. The incident occurred when the resident with a history of inappropriate sexual behavior was left unsupervised in another resident's room. The assigned 1:1 observation for the potential victim was not maintained due to a lapse in staff coverage during a shift change, and staff were unclear about their responsibilities regarding 1:1 supervision. Multiple CNAs and nurses reported not being informed about the need for close supervision or the specific risks posed by the resident with a history of sexual behaviors. As a result, the resident was able to enter another resident's room and engage in inappropriate contact without immediate intervention. Interviews and record reviews revealed that the facility's staff were not adequately trained or informed about the policies and procedures for preventing abuse, neglect, and exploitation, particularly in relation to residents with known behavioral risks. The lack of communication and documentation regarding supervision assignments, as well as the failure to review and act upon critical information in the admission packet, directly contributed to the incident. The facility's policies on abuse and neglect were not effectively implemented, and staff did not consistently follow procedures for monitoring and protecting residents at risk.
Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, resulting in one resident with a history of sexual behaviors inappropriately touching another resident. Both residents had severe cognitive impairment and behavioral issues, with one resident previously placed on 1:1 supervision due to aggression. Despite this, the resident was left alone in her room with another resident known for impulsive sexual behavior, leading to an incident where inappropriate contact occurred. Staff interviews and record reviews revealed that the assigned 1:1 supervision was not consistently maintained. The CNA assigned to 1:1 observation did not start her shift on time, and other staff were unaware of the need for close supervision or the specific behavioral risks of the residents involved. Communication lapses occurred during shift changes, and staff were not fully informed about the residents' histories or the requirements for 1:1 observation. Additionally, the care plans and admission documentation did not adequately reflect the residents' behavioral risks, and several staff members were unaware of the need for heightened supervision. The facility's policies required specific levels of observation and clear staff assignments for residents at risk, but these were not followed. The lack of proper hand-off procedures, incomplete staff training on observation protocols, and failure to review admission documentation for behavioral risks contributed to the incident. The deficiency was identified as Immediate Jeopardy due to the failure to provide the required supervision, which allowed the incident of inappropriate sexual contact to occur.
Failure to Account for and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure that drug records for a resident were properly maintained and that all controlled drugs were accounted for and periodically reconciled. Specifically, there was a missing count of hydrocodone for a resident with severe cognitive impairment and multiple medical diagnoses, including muscle weakness, pneumonia, and intellectual disability. The resident had an open-ended physician order for hydrocodone-acetaminophen as needed for pain, but medication administration records and controlled drug count sheets showed discrepancies in the number of pills received, administered, and remaining. On the morning in question, the nurses responsible for the medication cart did not perform the required narcotic count at shift change. This lapse was acknowledged by the staff involved, who could not provide a reason for failing to conduct the count. Later, during the evening shift change, it was discovered that a blister pack containing 30 hydrocodone tablets was missing. The staff and management were unable to locate the missing medication or the associated count sheet, and there were inconsistencies between the electronic medical record, paper count sheets, and the actual administration of the medication. Interviews with staff revealed that the system for monitoring controlled substances relied on shift change counts, but this process was not consistently followed. Further review of records and interviews indicated that the facility had received multiple cards of hydrocodone from both the pharmacy and hospice, but the documentation did not match the quantities received, administered, or remaining. The Director of Nursing, Assistant Director of Nursing, and Administrator were unaware of the discrepancies until notified by the surveyor. The pharmacy consultant and supervisor were also not informed of the missing medication at the time of the incident. The failure to conduct required shift change counts and maintain accurate records led to an official unknown count of hydrocodone, with a significant number of pills unaccounted for.
Improper Storage and Labeling of Lorazepam on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals, specifically liquid Lorazepam, on three of five medication carts. Observations revealed that Lorazepam, which required refrigeration as indicated by pharmacy labels, was found on medication carts instead of being stored in a refrigerator. In one instance, a nurse acknowledged the medication should have been refrigerated and took steps to move it after being observed. Additionally, one medication box had a damaged and illegible label, making it impossible to verify the resident's name, dosage, or administration instructions. Interviews with facility staff, including the FNP, DON, ADM, ADON, and a nurse, confirmed that staff were aware of the requirements for proper medication storage and labeling, including the need to refrigerate certain medications and ensure labels were legible and complete. Despite this, staff could not provide reasons for the observed deficiencies, and it was noted that some medications were received from hospice in an improper condition. Staff also reported that medication cart audits were conducted, but these audits failed to identify the improperly stored and labeled Lorazepam. The facility's policy required that controlled substances needing refrigeration be stored in a locked box within the refrigerator and that all medication labels include specific identifying information. However, the observed practices did not align with these requirements, as medications requiring refrigeration were left on carts and at least one medication label was illegible. The pharmacy consultant was unaware of the improper storage and could not provide information on the potential negative outcomes of these deficiencies.
Failure to Revise Care Plan After Resident Aggression
Penalty
Summary
The facility failed to review and revise a resident's comprehensive care plan by the interdisciplinary team after each assessment, specifically following two incidents of aggressive and physical behaviors toward other residents. The care plan for a male resident with multiple psychiatric and cognitive diagnoses, including dementia, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, depressive episodes, and schizoaffective disorder, was not updated to reflect new or additional interventions after aggressive incidents occurred. The care plan in place included general interventions for behavioral symptoms and physical aggression, but did not address the specific incidents that took place on two separate occasions. Record review showed that after each incident, the resident was placed on one-to-one supervision and alternative placement was considered, but there was no evidence that the care plan was revised to include these interventions or to address the new behaviors. Interviews with facility staff, including the MDS Coordinator, Social Worker, DON, ADM, and ADON, revealed a lack of clarity and communication regarding responsibility for care plan updates. Staff acknowledged that care plans should be revised after incidents, but were unaware that the resident's care plan had not been updated following the aggressive events. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, as well as after incidents or changes in the resident's condition. The deficiency was identified through observation, interview, and record review, which confirmed that the care plan was not revised after the resident's aggressive behaviors. Staff interviews indicated that while incidents were discussed in meetings, the care plan was not formally updated to reflect the new interventions or changes in the resident's status. The lack of care plan revision was not attributed to any specific reason by the staff involved, and there was inconsistency in understanding who was responsible for making such updates.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications. For two residents with severe cognitive impairment and diagnoses including generalized anxiety disorder and dementia, PRN orders for Lorazepam were not limited to 14 days as required, nor was there consistent documentation of a physician’s rationale for extending the orders beyond this period. In one case, a pharmacy consultant recommended a 90-day continuation, but this was not reflected in the physician’s order, and in another, there was no documented response to the pharmacy consultant’s recommendation. Record reviews showed that one resident received Lorazepam on several occasions without a 14-day stop date, and the medication administration records did not consistently align with the required documentation. Additionally, care plans did not always address the use of PRN psychotropic medications, and there was a lack of progress notes detailing the administration or monitoring of these drugs. Staff interviews revealed a lack of awareness and formal training regarding the 14-day stop date requirement, and there was no established system in place to monitor compliance with this regulation. Interviews with facility staff, including the DON, ADON, and administrative staff, confirmed that they were unaware of the missing 14-day stop dates and had not implemented a process to ensure compliance. The staff acknowledged the requirement and the facility’s policy but indicated that responsibility for ensuring the stop date was unclear, especially when medications were ordered by hospice or outside providers. The deficiency was further compounded by inconsistent communication and documentation between the facility, pharmacy consultant, and prescribing practitioners.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents, leading to a deficiency in the provision of Activities of Daily Living (ADL) care. Resident #1, a cognitively intact individual with a history of dementia, Parkinsonism, and hemiplegia, did not receive a shower on her scheduled days, despite requesting one. She was denied a shower by a CNA on 03/20/2025, and there was no documentation of her refusal or any attempt to reschedule her shower. Resident #1 expressed her dissatisfaction and confirmed she had not refused a shower. Resident #2, who is moderately cognitively impaired and requires substantial assistance, also did not receive a shower on her scheduled day. She expressed her desire for a shower and was told by a CNA that it was not her shower day. There was no documentation of her refusal, and she remained in her pajamas, indicating she had not been dressed for the day. Resident #3, slightly cognitively impaired and requiring moderate assistance, missed her scheduled showers due to being overlooked after moving to a new room. She confirmed she had not refused a shower and expressed her preference for showering on her scheduled days. Interviews with staff revealed a lack of coordination and communication regarding the shower schedule. CNAs were responsible for ensuring residents received showers, but there was confusion and neglect in fulfilling this duty. Some staff members were unaware of the residents' shower schedules, and there was a failure to document refusals or reschedule missed showers. The Director of Nursing and other staff acknowledged the importance of regular bathing to prevent infection and skin breakdown, but the deficiency occurred due to inadequate adherence to the facility's policies and procedures.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 9.38% due to three errors out of 32 opportunities. These errors involved two residents and were observed during a medication administration pass. LVN A was responsible for administering medications to the residents and made errors in timing and dosage. Specifically, Resident #6 received their Certizine medication late and was underdosed on Simethicone, while Resident #10 was underdosed on vitamin D3. Resident #6, an elderly female with neuropathy, congestive heart failure, and gastroparesis, was supposed to receive Certizine 10 mg at 7:00 AM and Simethicone 125 mg four times daily. However, during the observation, LVN A administered Certizine late and gave an incorrect dosage of Simethicone, providing only 80 mg instead of the prescribed 125 mg. Resident #10, also an elderly female with metabolic encephalopathy, protein-calorie malnutrition, and hypertension, was prescribed vitamin D3 125 mcg daily. LVN A administered only 25 mcg, failing to meet the prescribed dosage. Interviews with LVN A revealed that she was asked to take over medication pass duties unexpectedly, which contributed to the late administration of medication to Resident #6. LVN A admitted to not verifying the correct dosages before administration, leading to the underdosing of both residents. The facility's policy requires verification of the '5 Rights' of medication administration, which LVN A failed to follow, resulting in the observed deficiencies.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for residents during a meal observation. This deficiency was noted across all food forms served, including Regular, Mechanical Soft, and Pureed diets. During interviews, several residents expressed dissatisfaction with the taste and temperature of their meals, reporting that the food was often cold and lacked flavor. Observations by surveyors confirmed these complaints, with test trays showing that food items such as pork steak, mashed potatoes, and baked beans were served at inadequate temperatures and had poor taste and appearance. Interviews with staff revealed a lack of in-service training on food palatability and a disconnect between the kitchen and the serving process. A CNA mentioned regularly reheating food for residents due to complaints about cold meals, while the Dietary Manager acknowledged ongoing issues with food temperature and taste. The Administrator admitted to a lack of oversight in ensuring food remained hot from the kitchen to the residents, attributing the problem to delays in meal service. Despite having a policy on food handling, the facility failed to ensure its implementation, leading to resident dissatisfaction and potential risks of decreased food intake and weight loss.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with infection control protocols. During observations, it was noted that a medical assistant (MA A) did not sanitize a blood pressure cuff between its use on two residents, potentially facilitating cross-contamination. Additionally, a licensed vocational nurse (LVN A) failed to perform hand hygiene between administering medications to two different residents, despite being aware of the protocol. Further deficiencies were observed during wound care procedures conducted by another licensed vocational nurse (LVN B). LVN B did not adhere to enhanced barrier precautions (EBP) for residents with wounds, as required by the facility's policy. This included failing to don personal protective equipment (PPE) and neglecting to perform hand hygiene between glove changes while providing wound care to three residents. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene and the use of PPE to prevent the spread of infections. Interviews with the staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed gaps in training and awareness regarding infection control practices. LVN B admitted to not receiving formal training on wound care and infection control at the facility, although she had prior training in her career. The DON, who also serves as the infection preventionist, acknowledged that while staff had been trained on hand hygiene and EBP, there were lapses in compliance. The ADM was unaware of the non-compliance issues and emphasized the importance of following protocols to prevent infection spread.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to inform two residents, Resident #40 and Resident #32, or their responsible parties, about the risks and benefits of the proposed care and treatment involving the administration of Lorazepam, a medication used to treat anxiety disorders. Resident #40, a male with a history of paranoid schizophrenia, rhabdomyolysis, and generalized anxiety disorder, was administered Lorazepam without a signed consent form from either himself or his legal representative. Similarly, Resident #32, a female with unspecified dementia, panic disorder, and Alzheimer's disease, also received Lorazepam without the necessary consent documentation. Both residents had severe cognitive impairments, as indicated by their BIMS scores, which necessitated the involvement of their legal representatives in the consent process. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility's protocol required nurses to ensure consent forms were signed before administering psychotropic medications. The DON acknowledged that the absence of signed consent forms could lead to residents being uninformed about potential side effects, such as drowsiness, sedation, or increased risk of falls. Despite monthly and quarterly audits to monitor compliance, the facility failed to obtain the necessary consents for these residents, as confirmed by the review of the facility's policy on psychoactive medications, which mandates obtaining consent prior to administering such drugs, except in emergencies.
Failure to Limit PRN Psychotropic Drug Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days for two residents, leading to a deficiency in medication management. Resident #40, a male with a history of paranoid schizophrenia, rhabdomyolysis, and generalized anxiety disorder, had PRN orders for Lorazepam without a stop date, which extended beyond the 14-day limit. Similarly, Resident #32, a female with unspecified dementia, panic disorder, and Alzheimer's disease, also had PRN orders for Lorazepam without a stop date. Both residents were at risk for side effects due to the lack of a defined duration for their psychotropic medications. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility's nursing staff was responsible for ensuring residents were free from unnecessary medications. However, the DON was unaware of the PRN psychotropic medications without a 14-day stop date for the two residents. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documented a rationale for extending the order. The failure to adhere to this policy placed residents at risk for adverse effects from unnecessary medications.
Improper Medication Storage on Facility Carts
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals on two of its medication carts, leading to the presence of loose pills. During an observation of the medication cart at Station 1, two loose pills were found in the bottom drawer. The Licensed Vocational Nurse (LVN) responsible for the cart was unsure why the pills were loose and acknowledged it was her responsibility to ensure proper storage. Similarly, at Station 2, four loose pills were discovered in the medication cart drawer. The Medication Aide (MA) also expressed uncertainty about the presence of loose pills and confirmed her responsibility for proper storage. Both staff members recognized the potential for drug diversion or medication errors due to loose pills. The Director of Nursing (DON) and the Administrator (ADM) were unaware of the loose pills on the medication carts. They stated that it was the responsibility of the nursing staff to check the carts for loose pills and ensure proper storage. The facility's policy on medication storage, revised in January 2018, mandates that medications be stored in containers with pharmacy labels. Despite regular training and audits conducted by nursing administration and the pharmacy consultant, the presence of loose pills on the carts indicates a lapse in adherence to these procedures.
Improper Sanitization of Puree Machine in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation of pureed meals. During an observation, it was noted that the Dietary Manager (DM) did not allow the puree machine cannister to air dry between uses, as required by the facility's policy. After pureeing new potatoes, the DM cleaned the processor bowl, lid, and blade but did not allow them to air dry before reassembling and using them again for pureeing bread and carrots. This resulted in the equipment being reassembled with liquid still present, which could lead to food contamination. Interviews with the DM and the Assistant Dietary Manager (ADM) revealed that the DM was aware of the proper procedure, which includes allowing the puree machine cannister to air dry completely between uses. However, the DM admitted to skipping this step because he was in a rush due to late lunch tickets. The ADM confirmed that the DM had been trained on the correct procedure and acknowledged that not following it could result in contaminated food and potential illness for residents. The facility's policy, dated 2018, clearly states the requirement for air-drying utensils and equipment to prevent re-contamination and ensure the sanitizing solution has time to work effectively.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents within the building. The issue was identified when the facility did not follow the pest control company's instructions to repair multiple holes that rodents could use to access the building. These holes were identified between January 10, 2025, and February 25, 2025, but were not addressed in a timely manner, leading to continued rodent activity. Interviews with residents and their family members revealed that the presence of mice was a concern. One resident reported having papers chewed up by mice, while a family member of another resident found mouse droppings and evidence of mice in a drawer containing candy bars. These incidents indicate that the rodent problem was affecting the residents' living conditions and potentially their health. The facility was without a maintenance person for a period, which contributed to the delay in addressing the rodent issue. The previous maintenance man was reportedly not performing his duties adequately, leading to his dismissal. The facility eventually hired a new maintenance man, who began working on March 3, 2025, and started making progress in repairing the holes. The pest control company increased their visits to weekly until the problem was resolved, and the facility took additional steps to ensure cleanliness and monitor for new rodent activity.
Inaccurate ADL Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically in documenting Activities of Daily Living (ADL) care. The resident, a male with a history of cerebral infarction, muscle weakness, and reduced mobility, was documented as dependent on staff for showering, bathing, dressing, and toileting. However, on multiple occasions, the resident refused a bed bath, which was not accurately reflected in the documentation. Despite the resident's refusal, the Certified Nursing Assistant (CNA) documented that the resident received a shower/bath, indicating a discrepancy between the care provided and the records maintained. Interviews with the CNA revealed that she sometimes documented ADLs before completing them and did not update records if a resident refused care. The Director of Nursing (DON) and the Administrator acknowledged the importance of accurate documentation and the potential negative outcomes of inadequate ADL documentation, such as skin breakdown and infection control issues. The facility's policy on charting and documentation, last revised in 2012, requires accurate entries reflecting the date, time, and signature of the person recording the data, as well as documentation of any treatment refusals. However, there was no recent training provided to staff on proper documentation practices.
Failure to Provide Routine Showers for Residents
Penalty
Summary
The facility failed to provide routine showers for seven residents, as observed during a survey. The residents, who had various medical conditions such as transient ischemic attack, dementia, and end-stage renal disease, were not receiving regular hygiene care, including showers or bed baths. The lack of completed shower sheets and documentation indicated that the facility did not maintain records of when or if showers were provided, leading to residents expressing frustration and dissatisfaction with their care. Interviews with the residents revealed that they had not received showers for extended periods, with some residents stating they had not had a shower in weeks. The residents reported that they had to repeatedly request showers, and even then, the staff often did not follow through. The residents expressed feelings of embarrassment and frustration due to the lack of personal hygiene care, and some mentioned that the staff appeared too busy or uninterested in providing the necessary assistance. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services to maintain hygiene. However, the facility's failure to adhere to this policy was evident in the incomplete and blank shower sheets and the residents' grievances. The Director of Nursing and the Administrator acknowledged the issue, noting that the facility was short-staffed and that the problem had persisted for months, as documented in resident council minutes and grievance lists.
Resident Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal medical records. An observation was made where a Licensed Vocational Nurse (LVN) left a computer screen displaying a resident's medical information open and unattended on a medication cart at the nurse's station. This occurred while the LVN was on the opposite side of the nurse's station, allowing residents to walk by and potentially view the exposed information. The resident involved was a male with multiple complex medical conditions, including end-stage renal disease, atrial fibrillation, and severe sepsis, among others. The resident was moderately cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10. Interviews with the LVN, Director of Nursing (DON), and the Administrator revealed that the LVN acknowledged the mistake and admitted to not having recent privacy training due to new management. The DON and Administrator both expressed expectations that staff should lock or minimize screens when not in use to protect resident information. The facility's policy on electronic medical records, revised in June 2019, emphasizes the importance of safeguarding electronic protected health information (e-PHI) and limiting access to authorized personnel only. However, the incident demonstrated a lapse in adherence to these policies, resulting in a deficiency related to the privacy of resident medical records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving aggressive behavior by a resident with dementia. This resident, who was severely cognitively impaired, exhibited physical aggression towards other residents and staff. Despite documented aggressive behavior, the facility did not implement effective interventions to manage the resident's actions, leading to incidents where the resident pulled another resident out of bed and grabbed a third resident by the face. These incidents were not properly documented or investigated by the facility. Additionally, there were allegations of abuse involving the same resident and nighttime staff, which were not adequately addressed. The resident and a family member reported that the resident had been hit by a staff member, but these allegations were not investigated or reported to the appropriate authorities. Staff members were aware of the allegations but failed to follow the facility's abuse reporting procedures, citing issues such as lack of access to a working phone and the absence of the abuse coordinator during weekends. The facility's administration was unaware of the incidents and allegations, resulting in a lack of preventive measures to protect the residents involved. The facility's failure to investigate and document these incidents, as well as the lack of staff training on handling aggressive behavior, contributed to the ongoing risk of harm to residents. The facility's inadequate response to these incidents led to the identification of an Immediate Jeopardy situation by state surveyors.
Removal Plan
- Develop/Implement Abuse/Neglect Policies
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect for three residents. The Administrator (ADM) did not report allegations of abuse to the Health and Human Services Commission (HHSC) and failed to document investigation and prevention measures for incidents involving Resident #1. These incidents included an allegation of abuse by an unknown nighttime staff member, an injury of unknown origin, and two resident-to-resident altercations. Additionally, the ADM did not notify family members or assess the mental and physical effects on the involved residents. Resident #1, who was severely cognitively impaired and had a history of aggressive behavior, was involved in multiple incidents. These included being hit by a staff member, sustaining injuries of unknown origin, and engaging in altercations with other residents. Despite these events, there were no investigation reports available, and the facility staff failed to report the incidents to the appropriate authorities. Interviews with staff and family members revealed a lack of communication and documentation regarding these incidents. The facility's policies required immediate investigation and reporting of abuse allegations, but these were not followed. Staff members, including CNAs and the Assistant Activity Director, did not report the allegations to the ADM or the abuse preventionist. The facility's failure to adhere to its policies placed residents at risk for abuse and neglect, as evidenced by the Immediate Jeopardy identified by surveyors.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframes. Specifically, the Administrator (ADM) did not report several incidents involving a resident with dementia who exhibited aggressive behavior. These incidents included an allegation of abuse where the resident was reportedly hit by an unknown nighttime staff member, and two resident-to-resident altercations where the resident attempted to pull another resident out of bed and grabbed a third resident in the face. Additionally, an injury of unknown origin involving the resident was not reported or investigated. Interviews and record reviews revealed that several staff members, including CNAs, an Assistant Activity Director, and an LVN, failed to follow the facility's abuse policy by not reporting the allegations of abuse and neglect to the abuse preventionist or the ADM. The staff members cited various reasons for not reporting, such as the incident occurring over the weekend, the on-call phone not being answered, and assuming that the allegations had already been reported. The ADM was unaware of the incidents and did not report them to the Health and Human Services Commission (HHSC) because he was not informed by the staff. The facility's policy requires that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours after the allegation is made. The failure to report these incidents could place residents at risk for abuse and neglect. The ADM acknowledged that the staff should have reported the incidents to him and that he was responsible for reporting to HHSC. The facility's abuse prevention program includes procedures for identifying and reporting abuse, neglect, and exploitation, but these procedures were not followed in the reported incidents.
Failure to Investigate Allegations of Abuse and Resident Altercations
Penalty
Summary
The facility failed to investigate allegations of abuse, neglect, or mistreatment for three residents. Resident #1, a male with dementia and severe cognitive impairment, reported being hit by an unknown nighttime staff member. Despite the report, there was no evidence of an investigation into this allegation. Additionally, Resident #1 was involved in two resident-to-resident altercations on the same day, where he attempted to pull Resident #2 out of bed and grabbed Resident #3 in the face. These incidents were not documented or investigated by the facility. Interviews with staff revealed that there was a lack of communication and reporting regarding these incidents. Family Member M expressed concerns about Resident #1's injuries, which were not consistent with a fall, suggesting possible abuse. Staff members were aware of the allegations but did not report them to the Administrator or conduct an investigation. The Assistant Activity Director and CNAs were aware of the incidents but did not follow the facility's policy to report and investigate allegations of abuse, neglect, or mistreatment. The facility's policies on abuse investigation and resident-to-resident altercations were not followed. The Administrator, who was responsible for investigating and implementing resident protection measures, was unaware of the incidents. This lack of awareness and failure to investigate prevented the implementation of preventive measures to protect the residents involved. The facility's failure to document and investigate these incidents could place residents at risk for further abuse and neglect.
Failure to Update Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, who was admitted with diagnoses including unspecified dementia and other behavioral disturbances, exhibited increasingly aggressive behaviors that were not reflected in the care plan. The care plan, dated earlier in the month, did not include any information about the resident's physical and verbal aggressive behaviors, which had worsened over time. The resident's aggressive behaviors included hitting, kicking, and other physical actions that posed risks to both the resident and others. Despite these behaviors being documented in progress notes, the care plan was not updated to address these issues. The facility's policy required care plans to be revised and accurate to meet residents' needs, but this was not done in a timely manner. The facility experienced staff changes, including the resignation of the Director of Nursing and Assistant Directors of Nursing, which contributed to the oversight in updating the care plan. Interviews with staff revealed that the resident had been involved in multiple incidents of aggression towards staff and other residents. Staff reported feeling shaken by these incidents, and there was a lack of documented training or tools for staff to manage the resident's behaviors. The facility's administrator acknowledged the oversight in updating the care plan and attributed it to the challenging circumstances of losing key clinical staff members. The administrator admitted that the care plan should have been revised within a few days of the behaviors occurring, but this was not done due to the focus on staffing and other immediate needs.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the failure to administer Hydrocodone-Acetaminophen as prescribed. The resident, a female with a history of unspecified pain, atherosclerosis, and fractures, was not given her prescribed pain medication from 6 A.M. to 1:50 P.M. on the specified date. Despite having a care plan that included administering pain medications as ordered, the resident's request for Hydrocodone was not fulfilled due to issues with accessing the medication. The deficiency arose when the lock box containing the resident's narcotics could not be opened, preventing the administration of the prescribed Hydrocodone. The Assistant Director of Nursing sent an email to the pharmacy technician about the issue, but no medication was requested from the facility's emergency kit during the time the lock box was inaccessible. Interviews with staff revealed that the resident repeatedly asked for her Hydrocodone, but the staff did not provide an alternative pain medication or notify the physician to address the issue. The facility's emergency kit contained Hydrocodone, but staff were unaware of this and did not attempt to access it. The Director of Nursing demonstrated the emergency kit's functionality, which showed that Hydrocodone was available. The facility's policies indicated that emergency pharmacy services were available, but the staff did not follow the procedures to access the medication from the emergency kit. This oversight resulted in the resident experiencing unmanaged pain for several hours.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect, as evidenced by the handling of an allegation involving two residents. Resident #1 reported to the ADM that Resident #2 was being abused by staff, including CNA A, after hearing screams from Resident #2's room. Despite Resident #1's report, the ADM did not consider it an allegation of abuse and did not document or investigate the claim further. The ADM's decision was based on a conversation with the DON, who stated that Resident #2's screaming during ADL care was normal and that Resident #1 had a history of trying to move Resident #2 into her room. The ADM and the DON both failed to follow the facility's abuse policy, which requires immediate reporting and investigation of any allegations of abuse. The ADM did not interview any other staff or residents, nor did he review any records to corroborate the DON's assessment. Similarly, CNA A reported the incident to the ADON, but no further action was taken to investigate the allegation. The ADON also failed to report the incident to the ADM, as required by the facility's policy. The lack of documentation and investigation into the reported abuse allegation highlights a significant deficiency in the facility's adherence to its abuse prevention policies. The ADM, DON, and ADON all acknowledged their familiarity with the facility's abuse policy but did not follow the required procedures. This failure to act on the reported concerns could place residents at risk for abuse and neglect, as the facility did not ensure that all allegations were properly addressed and investigated.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe, as per their policy. The policy mandates that any alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, the allegations were not reported to the administrator or the state agency as required, which could place residents at risk for abuse or neglect. Resident #1, who has a diagnosis of dementia and altered mental status, reported to the administrator that she witnessed staff abusing Resident #2. She described hearing Resident #2 scream and seeing staff scratching and digging into Resident #2's stomach. Despite reporting this to the administrator, no immediate action was taken, and the incident was not documented or reported as an allegation of abuse. The administrator did not consider the report as an allegation of abuse and did not investigate further, relying on the DON's assessment that Resident #2's screaming was normal during ADL care. CNA A also reported an incident to the ADON, where Resident #1 accused her and her partner of abusing Resident #2. However, the ADON did not report this as an allegation of abuse, and no further investigation was conducted. The facility's failure to follow its abuse policy and report the allegations immediately could lead to abuse occurring without being discovered or addressed, as acknowledged by the ADM and DON during interviews.
Failure to Report Alleged Rough Handling of Resident
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent resident abuse, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, who had a history of Alzheimer's disease and other medical conditions, was reportedly handled roughly by a CNA during a transfer. This incident was observed by a family member who reported it to an LVN, but the LVN did not notify the administration as required by the facility's abuse prevention policy. The LVN, despite being trained on abuse and neglect reporting procedures, did not consider the report of rough handling as abuse and therefore did not report it to the Administrator. The facility's policy mandates immediate reporting of any allegations of abuse, but the LVN failed to act because the family member did not use the term 'abuse.' This oversight was confirmed by interviews with the Administrator and the DON, who both stated that the term 'rough' should have been considered reportable and investigated. The facility's abuse prevention policy, revised in October 2023, requires all staff to report allegations of abuse immediately. However, the LVN's failure to report the incident prevented the facility from investigating the matter and potentially placed residents at risk. The facility had conducted in-service training on abuse and neglect, emphasizing the importance of reporting, but the LVN did not adhere to these protocols, resulting in a deficiency in the facility's abuse prevention measures.
Failure to Timely Report Allegation of Rough Handling
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident who was reportedly handled roughly by a CNA during a transfer. The incident was reported by a family member to an LVN, who did not escalate the report to the Administrator or the Director of Nursing as required by the facility's abuse prevention policy. The LVN believed that the situation did not constitute abuse because the family member did not use the word 'abuse' and did not report the incident, which led to a delay in the investigation. The resident involved was an elderly female with severe cognitive impairment, Alzheimer's disease, and other medical conditions, including a recent hospitalization for fractured ribs. The family member observed the CNA being rough with the resident and expressed concern for the resident's safety and well-being. Despite the family member's report, the LVN did not document the incident in the resident's progress notes or the facility's incident records, and the allegation was not reported to the state agency within the required timeframe. Interviews with facility staff, including the Administrator, Director of Nursing, and other CNAs, revealed that the facility had policies and training in place for reporting abuse and neglect. However, the LVN's failure to report the incident as required by the facility's policy resulted in a delay in addressing the allegation. The facility's abuse prevention policy mandates immediate reporting of such allegations to the Administrator and state agency, but this protocol was not followed in this case.
Failure to Address Resident's Inappropriate Behavior in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with a history of exposing himself and urinating on the floor. The resident, who has Alzheimer's disease, major depressive disorder, dementia with agitation, generalized anxiety disorder, impulse disorder, and cognitive communication deficit, was admitted with severely impaired cognition and frequent urinary incontinence. Despite these issues, the resident's care plan did not address his behaviors of exposing himself and urinating in various areas of the unit, including other residents' rooms and common areas. Interviews with facility staff revealed that the resident's behavior was known but not documented in the care plan. Staff members, including a Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), and the Director of Nursing (DON), acknowledged the behavior but indicated that it was not addressed in the care plan. The DON was unaware of the behavior and stated that it should have been reported for monitoring and potential medical evaluation. The facility's policy requires staff to report new behaviors or changes from the resident's baseline to ensure they are included in the care plan, but this was not done in this case.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficiency was observed in the memory care unit, where there was inadequate supervision to assure resident safety. Specifically, the facility did not maintain the required staffing levels, as there were instances where only one staff member was present in the secure unit, leaving residents unsupervised. Two residents, a male and a female, were directly affected by this staffing deficiency. The male resident, diagnosed with Alzheimer's disease and other cognitive disorders, exhibited behaviors such as exposing himself and urinating on the floors. The female resident, also with severe cognitive impairments, displayed aggressive behaviors, including yelling, cursing, and physically aggressive actions towards other residents and staff. These behaviors were not adequately managed due to insufficient staffing, leading to unsupervised incidents and potential safety risks for all residents in the unit. Interviews with staff, including a Licensed Vocational Nurse (LVN), Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), revealed that the secure unit was often left with only one staff member, especially during breaks or when someone called in sick. This lack of supervision allowed the male resident to urinate in various areas and the female resident to wander into other residents' rooms, causing distress among other residents. The facility's policy required two staff members in the secure unit at all times, but this was not consistently followed, contributing to the observed deficiencies.
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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