Avir At Patriot
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 11490 Gateway North Blvd, El Paso, Texas 79934
- CMS Provider Number
- 676468
- Inspections on file
- 51
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 39 (1 serious)
Citation history
Health deficiencies cited at Avir At Patriot during CMS and state inspections, most recent first.
A resident with DM and multiple comorbidities was admitted on several oral hypoglycemics and later ordered insulin, but staff did not document routine blood glucose (BG) monitoring from admission. Over days, the resident complained of abdominal pain, nausea, vomiting, diarrhea, and poor intake, with repeated PRN opioid use for pain. A critical WBC of 30.9 K/uL was called in by the lab and handed by one LVN to another, yet there was no documentation that the physician or NP was notified, and the result remained pending review in the EHR. Concerned family members used a home glucometer and found BG values in the 400–500 mg/dL range, prompting calls to the physician, who ordered AC/HS BG checks, sliding-scale insulin, and Lantus; however, nursing staff did not document exact BG check times or insulin administration times, and BG values remained above 500 mg/dL. The resident became clammy, lethargic, then unresponsive with tachycardia, while attempts to reach the physician/NP went unanswered until the DON instructed staff to call 911; EMS found the resident unresponsive and transported her to the ED, where she was treated for severe metabolic derangements and later died.
A resident with multiple comorbidities and a recent below-knee amputation, admitted with a PRN hydrocodone-acetaminophen order for phantom pain, developed new abdominal pain and diarrhea, for which the physician ordered diagnostic tests and GI medications. Despite ongoing complaints of abdominal pain, high pain scores, ineffective Tylenol, refusal to eat, and observations of the resident crying and stating they had not eaten in days, LVNs repeatedly documented the symptoms and administered PRN hydrocodone but did not notify the attending physician or NP, as confirmed by the DON. The facility’s policy required prompt physician notification of significant changes in condition, and the medical director later stated the hydrocodone was intended only for phantom pain and that he should have been called about the abdominal pain. This failure to consult the physician and representative regarding a significant change in condition constituted the cited deficiency.
Two residents experienced multiple failures in clinical documentation, including missing entries for new physician orders, diagnostic tests, lab follow-up, critical lab notifications, and STAT insulin orders and administration. Nursing staff did not consistently record when labs and imaging were ordered, drawn, or communicated to the physician, and a STAT Lantus order and dose were not reflected on the Physician Order Summary or MAR despite being described in a nurse note. In addition, the DON and Dietary Manager did not document family concerns about diet, food portions, and dignity-related grooming practices, nor did they complete or record grievance follow-up regarding meals, dialysis sack lunches, and a missing personal blanket. These omissions show that the facility did not maintain complete and accurate medical records in line with its own charting and documentation policy.
A resident with dementia, ESRD, diabetes, and malnutrition had a family member who raised multiple grievances to nursing and dietary staff about undignified hair styling, inadequate dinner portions, protein intake, uneaten dialysis sack lunches, a missing blanket, and lack of inclusion in care plan meetings. Staff documented some of these concerns in nursing notes and verbally notified the Dietary Manager, but no grievance form was completed, no entry was made in the grievance binder, and the Social Worker and DON were not formally engaged through the facility’s grievance process. The facility’s written grievance policy, which required formal filing, investigation, and written responses to grievances, was not followed, and there was no documentation that the concerns were investigated or resolved per policy.
A cognitively intact, chairbound resident with progressive MS and morbid obesity reported that another cognitively intact, wheelchair-bound resident with a history of verbal aggression repeatedly yelled at her and called her a "cow," causing her anxiety and frustration. The verbally aggressive resident had prior documented incidents of yelling at and insulting peers and a roommate, including a previous episode of calling a female resident a cow. A receptionist directly witnessed the aggressive resident call the other resident a cow while he played dominoes and she sat nearby, acknowledged that this had happened before, and confronted him but did not report the incident to the Administrator, instead deferring to the victim’s preference not to report. This inaction occurred despite the facility’s abuse policy and prior ANE training requiring immediate reporting of any verbal abuse, resulting in a deficiency for failing to protect a resident from abuse and to promptly report allegations to administration.
A resident with diabetes, gangrene, and recent left BKA experienced several days of abdominal pain, nausea, vomiting, and diarrhea, with care plans directing close monitoring and physician notification for changes in condition. The attending physician ordered imaging and labs, but critical lab results, including an elevated WBC, were not reported and remained pending in the EHR. On the day of the event, the resident’s blood glucose rose from the 470s to over 560 mg/dL despite multiple insulin orders and administrations, with the LVN failing to document exact times of blood glucose checks and insulin doses. As the resident became clammy, lethargic, and then unresponsive with HR 194, staff reported making multiple unsuccessful attempts to reach the attending physician and NP, who was out of town and had no alternate physician designated. The DON then instructed staff to call 911, and the resident was sent to the ED, where she arrived unresponsive and later died. Surveyors found that the facility failed to ensure another physician supervised the resident’s care when the attending was unavailable and failed to ensure critical lab values and worsening condition were reported and addressed.
A resident with diabetes and multiple comorbidities experienced significantly elevated blood glucose and abdominal pain. After a family member checked a high blood glucose level, an LVN notified the physician, who ordered blood glucose checks with sliding-scale lispro and later additional STAT doses of lispro plus Lantus. The facility’s emergency insulin kit did not contain Lantus, so the weekend RN supervisor borrowed a new Lantus vial prescribed for another resident, administered it, and discarded the vial, despite training and policy prohibiting borrowing medications and re-use of single-dose vials. The STAT Lantus order and administration were not entered on the physician order summary or MAR, and the LVN did not document the times of blood glucose checks or insulin administration, contrary to facility policy requiring complete medication documentation.
A resident with ESRD, diabetes, and dementia developed a blood-filled blister and ecchymosis near a dialysis access site. Nursing staff notified the NP and initiated wound care, but did not immediately consult the physician or act on the family's and dialysis nephrologist's request to send the resident to the ER. The resident was only sent to the hospital after repeated requests, contrary to facility policy requiring prompt physician notification and action for significant changes in condition.
A resident with multiple medical conditions and cognitive impairment had family members file grievances regarding inconsistent call light placement and lack of staff responsiveness. The facility failed to document grievance resolutions, notify the family, and ensure staff followed procedures for monitoring call light accessibility, resulting in unresolved concerns about the resident's care.
A resident with multiple chronic conditions returned from dialysis with a blood blister and bruising on the chest. The assigned LVN documented only the blister, omitting the ecchymosis, and did not write a required physician telephone order for ER evaluation. The DON assessed the resident but failed to document the assessment. These actions resulted in incomplete and inaccurate clinical records, contrary to facility policy.
A nurse medication cart was found to contain an opened insulin vial that had expired, contrary to facility policy and manufacturer guidelines requiring removal of expired medications. Nursing staff, including an LVN, the DON, and the Administrator, confirmed that it is the responsibility of nurses to monitor and remove expired insulins from medication carts, but this had not occurred in this instance.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple urological conditions and a risk for impaired skin integrity did not have a weekly skin assessment documented as required by facility policy. Nursing staff either failed to perform or failed to document the assessment, with one LPN admitting to not recording the assessment and another believing an incident-related check was sufficient. The DON acknowledged a lack of quality assurance for verifying completion of these assessments.
A resident with multiple diagnoses, including IDD, received OT and was scheduled for ST after being identified as PASRR-positive, but the facility failed to submit the required NFSS authorization form within the mandated timeframe following the IDT meeting, resulting in a lapse in compliance with PASRR and state requirements despite therapy services being provided.
Two residents with cognitive impairments exited a facility unsupervised after a lab technician inadvertently held the door open. They were outside for 13 minutes before being assisted back inside. The incident highlighted a lapse in supervision and safety protocols.
Two residents with cognitive impairments eloped from the facility after a lab technician inadvertently held the door open for them. They were found unharmed within the premises, but the incident was not reported to the state survey agency as required by the facility's policy. The failure to report constitutes a deficiency in handling elopement risks and reporting procedures.
A resident with severe cognitive impairment and physical dependency was transferred using a mechanical lift without engaging the brakes on the lift and wheelchair, posing a risk of injury. Interviews revealed inconsistent training and understanding of proper procedures among CNAs, with facility policies lacking specific guidance on brake usage.
A facility failed to ensure call light accessibility and timely response, affecting a resident with Alzheimer's and two hallways. A resident's call light was out of reach, and call lights in two hallways were not promptly attended to, despite staff presence. The facility's policies on call light accessibility and response were not followed, leading to prolonged response times.
Two residents in a LTC facility were improperly restrained in their beds using fall mats propped up by furniture, which is considered a restraint. This action was not in line with their care plans or facility policies. Staff acknowledged the practice as inappropriate, and it was not reported or documented as required.
Two residents in an LTC facility were found restrained in their beds using fall mats and furniture, which was not an appropriate intervention for fall prevention. Both residents had significant medical histories that increased their fall risk, and staff acknowledged the setup was inappropriate. The deficiency was identified through observations and interviews, revealing a failure to maintain a safe environment and provide adequate supervision.
A facility failed to investigate allegations of mistreatment involving a resident who reported being pushed in a wheelchair, causing knee pain. Despite the resident's report, the CNA involved was not immediately suspended, contrary to the facility's abuse policy. Interviews with staff and the resident's roommate did not corroborate the mistreatment claims, but the facility's inaction posed a risk of continued abuse.
The facility failed to ensure accurate MDS assessments for two residents regarding their use of bed rails, which were not marked in the assessments despite being indicated in care plans and physician's orders. The MDS Coordinators did not consider bed rails as restraints and did not code them, leading to inaccuracies. The facility's policies did not address the accuracy of MDS assessments, potentially affecting resident care.
The facility failed to assess and obtain informed consent for bed rail use for two residents, leading to a deficiency. One resident, with rheumatoid arthritis and muscle weakness, was unable to use the bed rails and had no ongoing assessments. Another resident, with muscle wasting and a history of falls, also lacked assessments and consent. The facility did not attempt alternatives before installation, violating its policy.
A resident with dementia and mobility issues was identified as a fall risk, requiring a fall mat next to her bed as part of her care plan. However, during an observation, the mat was found folded behind the headboard, not in use. Interviews with staff revealed that the mat was supposed to be used whenever the resident was in bed, but it was forgotten. The DON confirmed the mat was a necessary intervention to prevent falls.
A resident on continuous oxygen therapy did not have the required oxygen warning signs posted outside their room, as observed during a survey. The facility's policy mandates these signs to ensure safety and proper monitoring. Both a nurse and the DON acknowledged the oversight, which posed a risk of inadequate monitoring and potential harm.
The facility failed to maintain accurate medical records for two residents, leading to potential treatment errors. One resident's diet was incorrectly documented as pureed instead of regular, while another resident's nebulizer treatment was not properly recorded. The DON acknowledged the errors, and staff interviews indicated no complaints from the residents. The facility's documentation policy requires accurate and timely records, which were not adhered to in these cases.
The facility failed to ensure appropriate use of psychotropic medications for two residents. One resident was prescribed Seroquel without a proper diagnosis, and another was given Zyprexa PRN without an end date. The DON acknowledged the lack of documentation for indications and end dates, which should have been addressed during medication audits. Additionally, Olanzapine was prescribed for agitation without a proper diagnosis, contrary to facility policy.
The facility failed to store and handle food according to professional standards, with issues such as an open bag of chips, a box of vegetables on the freezer floor, and condensation-soaked muffins. These practices, confirmed by the dietary manager and DON, risked contamination and bacterial growth, violating the facility's food safety policy.
A resident with severe cognitive impairment and functional limitations was unable to access or use the call light due to it being out of reach and not the preferred type. The facility's staff, including the DON and Therapy Director, failed to assess and accommodate the resident's specific needs for call light accessibility, contrary to the facility's policy.
A resident with limited range of motion did not receive appropriate treatment and services to maintain or improve mobility. Despite having functional limitations and being dependent on others for daily activities, the resident's care plan did not address the need for physical, occupational, or restorative therapies. Therapy services were discontinued due to a change in payment source, and the facility lacked a restorative program, posing risks such as contractures and skin breakdown.
The facility failed to provide adequate supervision and use of assistive devices for two residents. A resident with Alzheimer's and muscle weakness was improperly transferred by staff without using a gait belt, contrary to the care plan and facility policy. Another resident, with a history of falls, had a fall mat placed incorrectly, increasing the risk of injury. These actions did not comply with the facility's policies on fall prevention and safe handling.
A facility failed to properly label the enteral feeding formula for a resident, risking inadequate nutrition. The resident, unable to communicate, relied on a feeding tube due to conditions like cerebral infarction and respiratory failure. An LVN admitted to forgetting to label the feeding bottle, contrary to facility policy requiring specific labeling details.
A resident with dementia and on oxygen therapy was found with a nasal cannula misplaced, contrary to physician orders. Despite staff training, CNAs failed to ensure the nasal cannula was in place during their rounds, leading to a deficiency in care. The resident's oxygen saturation improved only after an LVN corrected the nasal cannula placement.
The facility failed to properly dispose of used cooking oil, leaving a barrel uncovered and nearly full, with trash and debris inside. This oversight was acknowledged by the DM, maintenance director, DON, and administrator, who all recognized the risks of pest attraction and potential spillage. Despite requests, the facility did not provide relevant policies and procedures.
A nursing assistant failed to follow proper hand hygiene and glove-changing protocols during incontinent care for a resident with dementia and muscle wasting, leading to a potential risk of cross-contamination. Despite receiving training, the assistant admitted to forgetting the procedures due to nervousness. The facility's policies emphasize the importance of hand hygiene and appropriate use of gloves, but the incident revealed a deficiency in the infection prevention and control program.
The facility failed to maintain a functioning oven, essential for meal preparation, leading to potential foodborne illness risks. Despite multiple repair attempts, the oven remained non-operational due to a solenoid relay issue and part backorder. The maintenance director and administrator were aware of the problem, but no alternative vendor was sought, and the facility's policy on essential equipment was not provided.
The facility failed to transmit MDS data to the CMS system within the required 14 days for several residents, resulting in significant delays. Residents had various medical conditions, and the MDS data, including discharge and death assessments, were overdue by 76 to 101 days. Interviews revealed confusion among staff regarding transmission responsibilities, and the CMS Submission Report confirmed that the data was only transmitted on the survey day.
A resident with Parkinson's disease and moderate cognitive impairment exited a facility and was left outside overnight due to inadequate supervision and a non-functioning door alarm. The resident was not discovered missing until the following morning, despite a CNA reporting his absence to the charge nurse twice during the night. The charge nurse did not verify the resident's whereabouts, and the incident was not documented in the facility's report log.
The facility failed to ensure adequate supervision and a safe environment, leading to an incident where a resident with a history of aggression was left unattended and hit another resident. Additionally, the Employee Lounge door was left open, posing a risk to residents who might enter and consume unsafe items.
The facility failed to maintain an infection prevention and control program, evidenced by an overflowing trash can at the Hall 100 nurse station and a housekeeper not adhering to COVID-19 protocols. The trash can was full and overflowing with various items, and the housekeeper did not call in sick before coming to work, risking the spread of infection.
A resident with severe cognitive impairment and multiple diagnoses was observed without a privacy cover on his catheter bag, compromising his dignity and privacy. Despite facility policy and staff acknowledgment of the requirement, the catheter bag was visible from the hallway, and the privacy cover was found clipped to the resident's wheelchair instead.
The facility failed to coordinate PASRR services for a resident with intellectual disabilities due to an issue with out-of-state insurance. Despite being PASRR positive and needing specialized services, the resident did not receive the necessary care. The facility's staff and local mental health authority were aware of the issue but did not take steps to resolve it, leading to a significant deficiency in the resident's care.
The facility failed to provide necessary wound care treatment for two residents, including not using gloves while handling gauze and not labeling wound dressings. These actions could lead to infection and improper tracking of wound care.
The facility failed to submit the Payroll Based Journal (PBJ) staffing information to CMS for the 1st quarter of the fiscal year 2023. The HR Coordinator submitted the PBJ to the Corporate Administrator, but it was not sent to CMS on time. This failure could place residents at risk for unmet personal needs and decreased quality of care.
Failure to Monitor Diabetes and Act on Critical Labs Leading to Resident’s Collapse
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for a resident with multiple comorbidities, including Diabetes Mellitus, coronary artery disease, hypertension, peripheral vascular disease, and a recent left below-knee amputation. The resident was admitted from an acute hospital with multiple oral hypoglycemic medications and later had orders for insulin glargine and insulin lispro with sliding scale coverage. Despite this, there was no documentation that blood glucose monitoring was performed from admission until the day of the acute event, even though the care plan called for diabetes medication as ordered, monitoring for side effects and effectiveness, and education on glucose monitoring. A family member reported that they were concerned that staff were not checking the resident’s blood sugar and brought the resident’s home glucometer to the facility, where they obtained readings in the 400s and 500s. The facility also failed to act on critical laboratory results and to promptly notify the physician or nurse practitioner of significant changes in the resident’s condition. On one date, the physician ordered a CBC with differential, comprehensive metabolic panel, lipase, and amylase, along with abdominal imaging, in response to new complaints of abdominal pain, diarrhea, and low appetite. The labs were collected the following morning, and the lab report later showed a critical WBC of 30.9 K/uL flagged as “CRITICAL HIGH” with a red octagon. A lab monitoring sheet showed the labs were collected, and a witness statement from an LVN indicated that when the laboratory called with the critical WBC result at 6:06 p.m., he answered the phone, wrote the result on a piece of paper, and immediately handed it to the LVN assigned to the resident, emphasizing the critical nature of the result and advising her to verify it in the portal. Video footage corroborated that the LVN received a piece of paper after the lab call. However, there was no documentation that the critical WBC result was reported to the physician or NP, and the lab result remained marked as pending review in the electronic record. In the days leading up to the resident’s decline, the resident repeatedly complained of abdominal pain, nausea, vomiting, diarrhea, and poor intake. Nursing notes documented multiple administrations of PRN hydrocodone for abdominal pain with high pain scores, and a family member reported that the resident had been complaining of stomach pain, throwing up, not eating, and having diarrhea for approximately two weeks. The family stated they had reported these symptoms to an LVN, who allegedly attributed them to dementia and did not assess the resident. On the day of the acute event, the family again found the resident weak, complaining of abdominal pain and nausea, and used their own glucometer to obtain blood glucose readings in the 400s. Nursing staff then notified the physician, who ordered blood glucose checks before meals and at bedtime, a moderate-dose sliding scale, and insulin doses including lispro and later Lantus. The nurse administered insulin but did not document the exact times of blood glucose checks or insulin administration. Subsequent blood glucose readings remained elevated above 500 mg/dL, and the resident became clammy, lethargic, and then unresponsive with a heart rate of 194. Multiple attempts were reportedly made to contact the physician and NP by phone and group text without response. The DON was informed that the resident’s condition was deteriorating, with fixed pupils and increasing lethargy, and instructed that the resident be sent to the ER. EMS was activated, and upon EMS arrival the resident was already unresponsive; she was transported to the hospital, where she was treated for altered mental status, severe acidosis, hypoxia, and hyperkalemia and was pronounced dead later that day. The facility’s failures included not monitoring blood glucose despite diabetes and multiple hypoglycemic medications, not documenting and acting on critical lab results, and not immediately notifying the physician of the resident’s worsening condition and unresponsiveness.
Failure to Notify Physician of Ongoing Abdominal Pain and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition and ongoing abdominal pain, as required by facility policy. A cognitively intact resident with a history of diabetes mellitus, hypertension, peripheral vascular disease, coronary artery disease, and a recent left below-knee amputation was admitted from an acute hospital and had active diagnoses including post-procedural pain and phantom pain. The resident’s care plan included monitoring and reporting pain, loss of appetite, refusal to eat, weight loss, and signs and symptoms of infection or adverse reactions to analgesic therapy to the physician. The resident had a PRN order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed for severe pain, with the diagnosis of phantom pain related to the recent amputation. On a medical visit, the attending physician documented a new complaint of abdominal pain and diarrhea with low appetite and ordered diagnostic tests, including abdominal ultrasound, KUB, and laboratory work, as well as medications such as Lomotil, Pepto Bismol, Dicyclomine, and PRN ondansetron. Radiology reports for the abdominal ultrasound and KUB indicated no acute process and no bowel obstruction or ileus, and these results were reported to the physician and nurse practitioner. Subsequent 24-hour report sheets and nursing documentation showed that the resident continued to complain of abdominal pain on multiple occasions. On one night, an LVN documented that hydrocodone was given and that the resident continued to complain of abdominal pain, but the DON stated that the LVN did not notify the attending physician or NP of the ongoing abdominal pain. Further documentation on another date showed that the resident was observed crying, stating that her stomach hurt and that she had not eaten in days, with dry lips noted. The LVN documented that Tylenol was not working, the resident was still in pain, and was refusing to eat, yet the DON reported that the LVN again did not notify the attending physician or NP of the continued abdominal pain. The MAR and administration notes showed multiple administrations of hydrocodone-acetaminophen for high pain levels, including pain scores of 7, 8, and 10, while the 24-hour report sheets continued to reflect that Tylenol was not effective and the resident remained in pain. The facility’s policy on change in a resident’s condition or status required prompt notification of the attending physician and resident representative within 24 hours of a significant change in the resident’s physical or mental condition, but interviews and record review confirmed that the nurses did not contact the physician or NP when the resident’s abdominal pain persisted. In an interview, the attending physician/medical director stated that he had ordered hydrocodone-acetaminophen specifically for phantom pain related to the recent amputation and that the nurses should have called him to report the resident’s abdominal pain. He indicated he would have given a new order and that he would not have approved the use of hydrocodone for abdominal pain because it could worsen the condition due to constipation. He also noted that the problem included the medication order not being entered into the electronic record with the specific indication of phantom pain related to the lower extremity amputation. The survey findings concluded that the facility failed to consult with the resident’s physician and representative when there was a significant change in the resident’s physical, mental, or psychosocial status, specifically by not notifying the physician when the resident continued to complain of abdominal pain on multiple occasions, contrary to facility policy and the resident’s care plan. The report also states that this failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The facility’s own policy required nurses to make detailed observations and gather pertinent information for the provider and to notify the physician within 24 hours of a change in the resident’s medical or mental condition, except in emergencies. Despite this, the documented ongoing abdominal pain, ineffective pain relief with Tylenol, refusal to eat, and high pain scores treated with hydrocodone were not communicated to the physician or NP by the LVNs involved, as confirmed by the DON. This sequence of inactions and omissions in physician notification and consultation formed the basis of the cited deficiency for failure to immediately tell the resident’s doctor and representative of situations affecting the resident.
Incomplete and Inaccurate Clinical Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with professional standards for two residents. For Resident #1, who had multiple comorbidities including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, and a recent left below-knee amputation, the attending physician evaluated her for new abdominal pain and diarrhea and ordered abdominal ultrasound (US), KUB, and multiple labs (CBC with differential, comprehensive panel, lipase, amylase). These new orders and subsequent diagnostic activities were not consistently or accurately documented. LVN C did not document on the date of the new orders that the physician had ordered labs and abdominal imaging, nor that labs were pending. RN A, the weekend supervisor, did not document when the abdominal US and KUB results were sent to the attending physician. On the following days, LVN C and LVN D did not document any follow-up on the lab orders that remained pending, and LVN H also failed to document follow-up on these same lab orders. When labs were finally drawn, LVN C did not document that the labs were drawn and that results were pending, and LVN D did not document at shift change that pending lab results had been reported to her. Further documentation failures occurred when critical lab results and insulin orders were communicated. LVN B did not document in Resident #1’s clinical record that he received a telephone call from the lab reporting critical lab results that had been outstanding for two days. He also did not document a telephone order from the physician for a STAT dose of Lantus 10 units when the resident’s blood glucose was elevated to 517 mg/dL, and this STAT Lantus order was not entered on the Physician Order Summary. The Medication Administration Record for the month did not show documentation that the STAT Lantus dose was administered as ordered. A nurse note by LVN B described the resident crying with abdominal pain, receiving PRN hydrocodone, having blood sugars of 473 mg/dL and then 515 mg/dL, and receiving multiple STAT doses of Lispro and Lantus per physician orders, but these insulin orders and administrations were not fully or accurately reflected in the formal order summary and MAR. Additionally, the DON and Dietary Manager did not document in the resident’s electronic record concerns voiced by the resident’s family member regarding the resident’s prescribed diet. For Resident #2, who had dementia, diabetes mellitus, hypertension, end-stage renal disease, adult failure to thrive, and malnutrition, the facility also failed to document family concerns and follow-up actions in the clinical record. The resident had a care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic diet, including a liberal renal diet with regular texture, health shake, HS snack, and potassium-rich foods for breakfast. The family member reported concerns about the food served for dinner on a specific date, stating the resident received a very small baked potato, small salad, and ice cream, and also raised concerns about how staff styled the resident’s hair with ponytails and bright-colored accessories, which the family felt did not treat the resident with dignity and respect. The family further reported that the resident did not eat the sack lunches sent to dialysis, that staff did not check the reusable blue bag upon return to see if the lunch was eaten, that a long-owned blanket had gone missing without being reported to administration or social work, and that care plan meetings were not consistently scheduled or that the family was not invited after staff changes. The DON acknowledged he did not keep notes and had not documented the family’s dietary concerns in the electronic record. The Dietary Manager acknowledged she had not completed a grievance/concern form, had not documented her follow-up calls to the family, and had not documented in the resident’s clinical record her follow-up on the concerns about the dinner meal. These omissions collectively demonstrate that the facility did not ensure that all services provided, changes in condition, and family concerns were documented in the residents’ medical records as required by the facility’s charting and documentation policy.
Failure to Follow Grievance Policy for Family Concerns About Hair Care and Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint policy and to ensure that a resident’s family grievances were formally recognized, investigated, and documented. A resident with dementia, diabetes mellitus, hypertension, end stage renal disease, adult failure to thrive, and malnutrition had an established care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic renal diet with supplements. On one evening, the resident’s family member voiced concerns to an LVN about how CNAs were combing the resident’s hair with ponytails, bright-colored ties, ribbons, and barrettes, which the family member felt did not treat the resident with dignity and respect. The same family member also raised concerns about the food served to the resident, including a dinner meal that appeared inadequate and concerns that the resident was not receiving enough protein. Nursing documentation showed that on the date of the complaint, the LVN recorded that the family member called about how CNAs were preparing the resident’s hair and that the LVN explained she would pass the information on to CNAs and nurses. A second nursing note documented that the Dietary Manager was notified that the family had concerns regarding food. However, review of the facility’s grievance binder revealed no grievance report from January onward related to the family’s concerns about the resident’s hair or food. The facility’s grievance policy required that grievances from residents or family members be filed, investigated by a designated grievance officer, and responded to in writing, but the grievance officer line on the policy was left blank, and there was no evidence that the concerns were processed through this system. Interviews further demonstrated that the concerns were not handled through the formal grievance process. The DON stated he had not been informed about the hair-combing concern and was not familiar with the facility’s grievance/concern procedures; he also acknowledged not documenting the family’s concerns about the resident’s diet in the clinical record. The Dietary Manager reported that she was not present when the family voiced concerns about the food, that she attempted to call the family twice, but she did not complete a grievance/concern form or document her follow-up in the resident’s record. The Social Worker, who was responsible for completing grievance/concern forms, stated that no one had reported the family’s concerns about the resident’s hair or food to her. As a result, the family’s grievances regarding the resident’s hair styling, the adequacy and type of food served, the uneaten dialysis sack lunches, the missing blanket, and care plan meeting participation were not entered into the grievance system, not investigated per policy, and not responded to in writing as required. Additional observations and interviews highlighted the underlying events but did not change the fact that no formal grievance process was initiated. Staff reported that the resident did not eat her packed dialysis lunches due to nausea and that the lunches were returned untouched, while the family member believed staff were not checking the bag upon the resident’s return. The resident herself stated she liked the way staff had previously combed her hair with ponytails and accessories but that this stopped after her family member objected; she appeared sad and said she would do whatever her family member wanted. The family member also reported that a long‑owned blanket had gone missing and that staff only replaced it with another blanket and asked if it had been labeled, without escalating the issue to administration or the Social Worker. The family member further stated that she had not been invited to care plan meetings after staff changes and that a scheduled care plan conference had been canceled and not rescheduled. None of these concerns were captured in the grievance binder or processed according to the written grievance/complaint policy, constituting the cited deficiency.
Failure to Report and Prevent Ongoing Verbal Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse and to ensure that allegations of abuse were immediately reported to the Administrator. One resident with progressive multiple sclerosis, morbid obesity, and dependence on assistance for ADLs reported that another resident repeatedly called her a “cow” and yelled indirectly at her when passing by her room. She was cognitively intact, oriented, and able to make herself understood. Her care plan documented episodes of adverse behaviors and a potential mood problem related to an incident in which another resident called her a cow, with approaches including behavioral health consultation and monitoring for mood symptoms. The resident alleged that the verbally aggressive resident yelled at others, called her a cow, and made loud, annoying noises when passing her room, which made her feel anxious and frustrated because staff were not stopping him. A friend of this resident stated that the name-calling and yelling had been occurring for approximately a year and a half, including after the verbally aggressive resident was moved to another hall, and that these behaviors occurred more often on weekends. The friend reported that the resident who was being called names had limited physical strength due to multiple sclerosis and that the verbally aggressive resident threatened to hit her. The friend also stated she had reported these concerns to the Administrator the previous year. The resident identified as verbally aggressive was cognitively intact, used a wheelchair, and had documented verbal aggression, including insulting male peers and yelling at a roommate about TV volume. His care plan and psychological assessments noted verbal aggression, anxiety, and depressive disorder, with a risk of verbal aggression. Facility records showed prior incidents of altercations and name-calling involving this resident, including an altercation reported to the state and an incident of calling another resident a cow. Despite this history, multiple CNAs and an LVN reported they had not personally witnessed him insulting or name-calling other residents, though they acknowledged he spoke loudly and made other residents uncomfortable. A key event leading to the deficiency was an incident witnessed by the weekend receptionist approximately one month before her interview. She observed the verbally aggressive resident in the living room playing dominoes and the resident with multiple sclerosis in the reception area when he called her a cow. The receptionist stated this resident had done this before, and she moved the resident with multiple sclerosis at that time. She confronted the verbally aggressive resident and told him not to repeat the behavior, but she did not report the incident to anyone in the facility, despite having been trained via email on abuse, neglect, and exploitation to immediately report verbal abuse to the Administrator. She stated she asked the resident who was called a cow if she wanted it reported, and when the resident said no, she chose not to report it, telling her that if it happened again she would have to report it. The Administrator later stated that staff were expected to immediately report any allegation of abuse, neglect, and mistreatment and that failure to do so placed residents at risk of further abuse. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that residents have the right to be free from abuse, including verbal and mental abuse, and that the program includes protecting residents from abuse by anyone, providing staff training on abuse prevention and reporting, and investigating and reporting any allegations within required timeframes. The failure of the receptionist to immediately report the witnessed verbal abuse incident to the Administrator, in the context of a resident with a documented history of verbal aggression and prior incidents of calling another resident a cow, led to the cited deficiency for not protecting the resident’s right to be free from verbal and physical abuse and not ensuring immediate reporting of abuse allegations.
Failure to Ensure Physician Coverage and Response to Critical Labs and Hyperglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that another physician supervised the medical care of a resident when the attending physician was unavailable, and to appropriately act on critical clinical information and worsening condition. The resident was admitted from an acute hospital with diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, gangrene, and a recent left below-knee amputation. The care plan identified diabetes management, infection related to gangrene, and significant pain management needs, with instructions to monitor and report changes in mental status, behavior, appetite, and pain, as well as signs and symptoms of infection and adverse reactions to analgesics. The resident had been complaining of abdominal pain, nausea, vomiting, and diarrhea over several days, and the attending physician ordered a KUB, abdominal ultrasound, and labs, including amylase and lipase. Radiology reports for the KUB and abdominal ultrasound showed no acute process and no bowel obstruction or ileus, and these results were reported to the physician and NP. However, critical lab values, including an elevated WBC indicating possible sepsis, were received on a prior date and remained pending review in the electronic record, meaning they were not reported to the attending physician or NP. The attending physician later stated that if he had known about these lab results, he would have sent the resident to the hospital, and that the critical WBC and rising blood glucose indicated the resident was acutely ill and going into full sepsis. The resident continued to complain of abdominal pain and had poor appetite, and the physician documented follow-up visits and ordered medications such as Bentyl and Zofran PRN, but there is no documentation that the critical lab values were communicated to him or that he was notified of ongoing ineffective pain control or persistent abdominal symptoms over the days in question. On the day of the acute event, the resident’s family checked the resident’s blood glucose with their own glucometer and obtained a reading of approximately 470–495 mg/dL. The LVN notified the RN weekend supervisor and the attending physician, who ordered initiation of a moderate sliding scale insulin regimen, blood glucose checks AC and HS, and 10 units of Lantus. After 10 units of Lispro were given, a recheck about 45 minutes later showed the blood glucose had increased to 517 mg/dL. The LVN reported this to the physician, who then ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, administration of 14 units of Lispro STAT, and 10 units of Lantus STAT. The LVN did not document the exact times of the blood glucose checks or insulin administrations, although he acknowledged being trained to do so. The facility did not have Lantus in the insulin E-kit, and the RN supervisor borrowed a vial from another resident. Later that afternoon, the resident’s blood glucose was rechecked and found to be 563 mg/dL. The LVN reported that the resident became clammy, increasingly lethargic, and then unresponsive, with a heart rate of 194 and fixed pupils. Multiple attempts were made by the LVN and weekend supervisor to contact the attending physician and NP by phone and group text, but they reported receiving no response. The DON confirmed that the attending physician, who was also the medical director, was out of town on vacation and that the NP assigned to the facility did not answer calls or texts. The DON instructed the nurse to call 911 and send the resident to the ER due to the change in condition. EMS was activated, and the resident was transported to the hospital, where she arrived unresponsive with a blood glucose of 561 mg/dL, hypotension, hypoxia, and required CPR and intubation. Despite resuscitation efforts, the resident expired in the ED. The attending physician later denied receiving calls or texts on the day of the event and stated that he and his NPs were always available and that he did not see a need for an alternate physician when he was out of town. The facility was unable to provide a policy and procedure on physician services to the surveyor prior to exit. The surveyor concluded that the facility failed to ensure another physician was available to supervise the medical care of the resident when the attending physician was unavailable and failed to ensure that critical lab values and ongoing changes in condition were reported and acted upon. This failure occurred for one resident reviewed for physician services and was associated with the resident’s continued worsening condition, severe hyperglycemia, unresponsiveness, transfer to the hospital, and subsequent death. The report states that this failure could place residents at risk of delayed treatment or intervention, decline in health, and/or death.
Failure to Maintain Emergency Insulin Supply and Proper Medication Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically insulin, for a resident with diabetes mellitus. The resident had multiple active diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, post-procedural pain, and aftercare following a left below-knee amputation. The care plan identified diabetes mellitus with approaches including diabetes medication as ordered, monitoring for side effects and effectiveness, and monitoring for signs and symptoms of hypoglycemia and infection. The resident was cognitively intact with a BIMS score of 15 and had an existing physician order for insulin glargine (Lantus) 10 units subcutaneously at bedtime and insulin lispro per a sliding scale. On the day of the incident, the resident complained of abdominal pain and diarrhea, and the attending physician had recently evaluated the resident and ordered Bentyl and Zofran PRN. Later, the resident reported abdominal pain rated 8/10, for which PRN hydrocodone was administered. A family member checked the resident’s blood glucose, which was in the 470s mg/dL range, and the physician was notified. The physician ordered blood glucose checks before meals and at bedtime with a moderate sliding scale and a STAT dose of 10 units of lispro, which the LVN reported administering, although he did not document the actual times of the blood glucose checks or insulin administration in the electronic record. A recheck of blood glucose approximately 45 minutes later showed an increase to over 500 mg/dL, and the resident became clammy and reported feeling sleepy. After the blood glucose remained elevated, the physician was notified again and ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, a STAT dose of 14 units of lispro, and administration of 10 units of Lantus. The facility’s emergency insulin kit did not contain Lantus, so the weekend RN supervisor obtained a new vial of Lantus that belonged to another resident and used it to administer the ordered dose, then discarded the vial in a biohazard container. This borrowing of medication from another resident occurred despite staff training and facility policy stating that medications must be administered as prescribed, that single-dose vials are not to be used for multiple residents, and that medication administration details, including date, time, dosage, route, and results, must be documented. The physician’s STAT order for Lantus and its administration were not entered on the physician order summary or the MAR. Subsequently, the resident’s condition deteriorated, with a blood glucose reading in the 560s mg/dL range, tachycardia, clamminess, and unresponsiveness, leading to EMS activation and transfer to the hospital, where the resident was treated for altered mental status and later pronounced dead. The surveyors concluded that the facility failed to ensure the emergency insulin kit contained Lantus and that staff borrowed insulin from another resident, constituting a failure to provide required pharmaceutical services. The hospital emergency department record documented that the resident arrived unresponsive with a blood glucose of 561 mg/dL, low blood pressure, and oxygen saturation less than 90%, requiring bagging and chest compressions by EMS. The ED course included emergent intubation, CPR, findings of hyperkalemia, severe acidosis, and hypoxia, and eventual cessation of resuscitation efforts at the family’s request, with time of death recorded. Facility nursing notes and interviews confirmed that lab results from a prior day showing rising glucose had not been reported to the physician until the day of the event, that the resident’s glucose continued to trend upward, and that the DON was informed the resident had received 14 units of lispro and 10 units of Lantus per MD order. Interviews with the LVN and RN supervisor confirmed that Lantus was not available in the insulin emergency kit, that a vial was borrowed from another resident, and that this practice was contrary to their training and facility policy. The physician’s STAT Lantus order and its administration were not reflected in the physician order summary or MAR, further evidencing failures in documentation and medication management. Overall, the survey findings show that the facility did not ensure that its emergency insulin kit contained Lantus as needed for STAT administration and that staff resorted to borrowing another resident’s Lantus vial to comply with the physician’s order. Additionally, required documentation of blood glucose checks and insulin administration times, as well as entry of the STAT Lantus order on the physician order summary and MAR, was missing. These actions and omissions were inconsistent with the facility’s own medication administration policy, which requires medications to be administered as prescribed, prohibits using single-dose vials for multiple residents, and mandates complete documentation of medication administration details in the resident’s medical record.
Failure to Notify Physician and Act on Family Request for Hospital Evaluation
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically the development of ecchymosis and a blood-filled blister near the dialysis access site. The resident, who had a complex medical history including end-stage renal disease (ESRD) on hemodialysis, diabetes mellitus type II, anemia, GI bleed, and dementia, was noted to have a blood-filled blister and maroon ecchymosis on the chest after returning from dialysis. The initial response by nursing staff was to notify the Nurse Practitioner (NP), who ordered wound care and antibiotics, but did not address the request for hospital evaluation made by the dialysis nephrologist and the resident's family. Despite multiple notifications from the dialysis center and the resident's family, nursing staff questioned why the dialysis center had not sent the resident directly to the emergency room and did not immediately act on the nephrologist's recommendation or the family's request. The family member expressed frustration and concern over the staff's reluctance to send the resident to the hospital, as did the dialysis center staff, who clarified that they could not send residents to the ER for non-emergent situations and had communicated the nephrologist's recommendation to the facility. The resident was eventually sent to the emergency room, but only after significant delay and repeated requests from the family and dialysis center. Interviews with facility staff, the NP, the medical director, and the attending physician confirmed that the nurses should have contacted the resident's physician to obtain an order for hospital evaluation as requested by the family and the nephrologist. Facility policy required prompt notification of the physician and resident representative in the event of significant changes in condition or the need for hospital transfer, but this was not followed in this case. The delay in consulting the physician and acting on the family's request constituted a failure to follow policy and could have resulted in delayed medical treatment for the resident.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts to resolve grievances voiced by a resident's family, as required by both regulation and facility policy. The family filed grievances on two separate occasions regarding the resident's care, specifically about the placement and accessibility of the call light and the conduct of night staff. Documentation revealed that the grievance forms were incomplete, lacking information on the resolution, notification to the family, and signatures. The facility's grievance policy required written responses and notification of findings, but these steps were not followed. The resident involved was an elderly female with multiple complex medical conditions, including recurring urinary tract infections, renal failure, diabetes mellitus, and was on hospice care. She was cognitively moderately impaired and dependent on staff for most activities of daily living, including mobility, hygiene, and toileting. The family reported that the resident was unable to operate the call bell unless it was placed on her chest, and staff were inconsistent in ensuring the call light was within reach. Despite interventions discussed with the clinical team, such as implementing a sign-in log for staff to document call light placement, the log was not consistently posted or used, and staff had not been trained on its use. Interviews with staff and family confirmed that the sign-in log was missing for a period, and staff were not consistently checking or documenting call light placement as required. The family also reported that staff did not check on the resident throughout the night, and that their concerns about staff empathy and visitation were not adequately addressed or documented. The facility's failure to document grievance resolutions and notify the family as per policy contributed to the deficiency.
Incomplete and Inaccurate Clinical Record Documentation for Resident with Chest Injury
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who returned from a dialysis center with ecchymosis and a blood blister in the middle of the chest. The assigned LVN documented the presence of a blood-filled blister in the Event Report but omitted the ecchymosis surrounding the blister, despite having observed both. The LVN also did not write a physician's telephone order for the nurse practitioner's directive to send the resident to the emergency room for evaluation, as required by facility policy. The Director of Nursing (DON) assessed the resident the following day after being notified of the incident but did not document this assessment in the resident's clinical record, contrary to facility policy and training. Interviews confirmed that both the LVN and DON were aware of the need to document all assessments and physician orders in the electronic clinical record but failed to do so in this instance. The facility's policy requires that all services, changes in condition, and events be documented objectively and completely by licensed personnel. The resident involved had a complex medical history, including end-stage renal disease on hemodialysis, diabetes mellitus type II, anemia, gastrointestinal bleeding, and dementia. At the time of the incident, the resident was alert and able to communicate, reporting no pain from the chest bruise and blister. The lack of complete and accurate documentation regarding the resident's condition and the care provided resulted in a deficiency related to the maintenance of clinical records.
Expired Insulin Vial Found in Medication Cart
Penalty
Summary
A deficiency was identified when a nurse medication cart was inspected and found to contain an opened insulin vial that had exceeded its allowable usage period. The insulin vial was labeled with an open date, and upon review, it was determined that the vial had expired based on the facility's policy and manufacturer instructions, which state that opened insulin vials are only good for 28 to 31 days. The nurse present during the inspection acknowledged that she had not noticed the vial had expired and stated that it was each nurse's responsibility to monitor for expired medications. The Director of Nursing (DON) and the Administrator both confirmed that nursing staff are expected to remove expired insulins from medication carts. Facility policy documents reviewed indicated that outdated or expired medications are to be immediately removed from stock and disposed of according to procedures. Manufacturer instructions for insulin also specify that opened vials should be discarded after 31 days. The failure to remove the expired insulin from the medication cart was observed during the survey, and staff interviews confirmed that the expired medication had not been identified or removed as required by policy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of an effective program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Document Weekly Skin Assessment as Required by Policy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not ensuring that a weekly skin assessment was documented in accordance with facility policy. The resident in question was an older male with a history of nephrostomy tube malfunction, bilateral hydronephrosis, left hydroureter, and displacement of a left percutaneous nephrostomy tube. His care plan included interventions for risk of impaired skin integrity and required weekly skin checks. However, review of July 2025 records showed no skin assessment was completed for the week of 07/21-07/25. Interviews with nursing staff revealed that the assigned LVN did not document the required weekly skin assessment, initially stating it was not done because a previous assessment had been completed a few days earlier, and later admitting to having performed but not documented the assessment. Another LVN also failed to complete the scheduled weekly assessment, believing an incident-related assessment was sufficient. The DON confirmed that while weekend audits were being conducted, there was no quality assurance process in place to verify completion of weekly skin assessments. The facility's documentation policy required objective observations and treatments to be recorded, but this was not followed in this instance.
Failure to Submit Timely PASRR NFSS Authorization for Therapy Services
Penalty
Summary
The facility failed to coordinate assessments and submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting for a resident identified as PASRR-positive. The resident, a female with diagnoses including cerebral palsy, non-Alzheimer's dementia, hemiplegia, hemiparesis, traumatic brain injury, anxiety, and depression, was determined to meet criteria for intellectual/developmental disability (IDD) following a PASRR Level 1 screening and subsequent evaluation. The Local Authority Compliance Confirmation indicated the need for PASRR services, including participation in IDT meetings, habilitation services, and monitoring for possible community transition. Despite the resident receiving occupational therapy (OT) and being scheduled for speech therapy (ST), the facility did not submit the required NFSS form within the mandated 20-day period following the IDT meeting. Interviews with facility staff, including the DON, MDS Coordinator, and DOR, revealed that the NFSS forms were left in draft status and never officially submitted, resulting in no authorization for payment for the therapy services provided. The staff indicated that the failure to submit the NFSS was due to a misunderstanding regarding the resident's refusal of services and the continuation of existing therapies, as well as a lack of clarity about staff responsibilities for form submission. The facility's PASRR policy did not reference the 20-day deadline for NFSS submission, and the staff involved at the time of the deficiency were no longer employed at the facility. Documentation confirmed that the resident continued to receive therapy services during the period in question, but the required authorization process was not completed in accordance with state regulations. The deficiency was identified through record review and staff interviews, which confirmed the lapse in compliance with PASRR and NFSS requirements.
Elopement Incident Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for two residents, leading to an elopement incident. Both residents, who had cognitive impairments and a history of wandering, exited the facility through the front door. The incident occurred when a lab technician inadvertently held the door open for visitors, allowing the residents to leave. The residents were outside the facility for approximately 13 minutes before being assisted back inside. Resident #2, a male with severe cognitive impairment and a history of wandering, was found outside the facility with another resident. His medical history included Parkinson's disease, dementia, and repeated falls. He was unable to recognize stop lights or take necessary precautions when crossing streets. Similarly, Resident #3, who also had cognitive impairments and a history of wandering, was found outside with Resident #2. His medical history included dementia and paranoid schizophrenia, and he was noted to be very confused and unable to respond to questions. The facility's failure to provide adequate supervision and prevent the residents from exiting the facility placed them at risk of injury. The incident was identified as an Immediate Jeopardy, which began and ended on the same day. The facility had corrected the noncompliance before the survey began, but the deficiency highlighted a significant lapse in supervision and safety protocols.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, specifically related to the elopement of two residents, within the required timeframes to the state survey agency. The incident involved two residents who were found outside the facility after a lab technician inadvertently held the door open for them. Both residents were brought back into the facility without injuries, but the incident was not reported to the state survey agency as required by the facility's policy. Resident #2, a male with severe cognitive impairment due to Parkinson's disease, dementia, and other conditions, was assessed as being at risk for elopement. His care plan included interventions to distract him from wandering. On the day of the incident, he was found outside the facility with another resident, Resident #3, who also had cognitive impairments. Both residents were seen on security footage exiting the facility and were later found by a dietary aide within the premises. The Director of Nursing (DON) and the Administrator were informed of the incident, but the decision was made not to report it to the state survey agency, as the residents were found unharmed and within the facility's premises. The facility's policy required reporting such incidents, but the Administrator determined that the situation did not constitute neglect. The failure to report the incident as per the facility's policy and state requirements constitutes a deficiency in the facility's handling of elopement risks and reporting procedures.
Failure to Ensure Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in using mechanical lifts for resident transfers, specifically for a resident with severe cognitive impairment and physical dependency. During an observed transfer, two CNAs did not engage the brakes on the mechanical lift and wheelchair, which are critical safety measures to prevent movement and potential accidents. The resident involved was a female with dementia, muscle weakness, and cognitive communication deficit, requiring mechanical lift assistance for transfers. Interviews with the CNAs revealed a lack of consistent training and understanding of the proper procedures for using mechanical lifts, as one CNA believed the lift brakes were only necessary when lowering a resident. The Director of Nursing and Director of Rehabilitation both acknowledged the importance of engaging brakes during transfers to prevent movement and potential safety risks. However, there was uncertainty about the frequency of training, and the facility's policy and the lift's manual did not provide specific guidance on when to engage brakes during transfers.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation for their needs and preferences, specifically regarding the placement and response to call lights. Resident #5, who was diagnosed with Alzheimer's Dementia and other conditions requiring substantial assistance, was found on two occasions with the call light out of reach while in bed. Despite the care plan indicating the necessity for the call light to be within reach, observations showed it was on the floor, and staff interviews confirmed the importance of having the call light accessible to residents. Additionally, the facility did not respond promptly to call lights in two hallways. Observations on Hall 300 revealed that call lights in two rooms were on for 21 and 26 minutes, respectively, without staff entering the rooms, despite staff walking past. Similarly, in Hall 400, a call light was on for 31 minutes without any staff presence in the hallway. Interviews with the DON and staff indicated that call lights should be responded to promptly, and the facility's policy required all staff to respond to activated call lights. The facility's policies on call light accessibility and timely response were not adhered to, as evidenced by the prolonged response times and the failure to ensure call lights were within reach of residents. The DON acknowledged the importance of timely responses and the potential for resident agitation if needs were unmet. However, there was no process in place during shift changes to ensure call lights were attended to, contributing to the deficiency.
Improper Use of Physical Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment. Specifically, two residents were restrained in their beds using fall mats propped up by furniture, which is considered a restraint. This action was not in line with the residents' care plans or the facility's policies, which emphasize the importance of treating residents with respect and dignity and ensuring their freedom from unnecessary restraints. Resident #4, a female with dementia and other cognitive impairments, was admitted to the facility with a high risk of falls. On the day of her admission, a fall mat was placed against her bed and held in place by a chair, restricting her movement. This was done without proper justification or documentation, and staff members acknowledged that it was inappropriate and considered a restraint. Interviews with staff revealed that this was done as a temporary measure while waiting for a bed that could be lowered, but it was not an acceptable practice. Similarly, Resident #5, a male with Alzheimer's dementia and a history of falls, was also found to have a fall mat placed against his bed with furniture propped against it. This was not in accordance with his care plan, which required a fall mat to be placed on the floor next to his bed. Staff interviews confirmed that this practice was not reported or documented, and it was acknowledged as inappropriate and a restraint. The facility's policies on incident reporting and fall prevention were not followed, leading to these deficiencies.
Inappropriate Use of Fall Mats as Restraints
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. The deficiency was observed when staff used furniture and fall mats to block residents in bed, which was considered a restraint. Specifically, one resident was found lying in bed with fall mats placed sideways against the bed, with a chair and nightstand pushed up against them. Another resident was similarly restrained with a fall mat and furniture, which was not an appropriate intervention for fall prevention. The residents involved had significant medical histories that increased their risk of falls. One resident was diagnosed with dementia, muscle weakness, and cognitive deficits, requiring substantial assistance for mobility and transfers. The other resident had Alzheimer's dementia and was at risk for falls due to impaired thought processes and lack of coordination. Both residents were assessed as high fall risks, and their care plans included interventions to prevent falls, but the use of fall mats as restraints was not part of these plans. Interviews with staff revealed that the use of fall mats and furniture as restraints was not a standard practice and was not reported to supervisors. Staff members, including CNAs and LVNs, acknowledged that the setup was inappropriate and could be considered a restraint. The Director of Nursing and the Administrator also confirmed that such practices were not acceptable and that better interventions were available. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure in maintaining a safe environment and providing adequate supervision for residents at risk of falls.
Failure to Investigate Allegations of Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one resident. The incident involved a resident who reported being mistreated by a CNA, specifically stating that her legs were thrown into the bed and that she was pushed in her wheelchair, causing her knee to hit the wall. Despite these allegations, the facility did not immediately suspend the CNA involved, as required by their abuse policy, which could have placed residents at risk of potential continued mistreatment and abuse. The resident in question was an elderly female with diagnoses of muscle weakness, gait abnormalities, and lack of coordination, who required moderate assistance with transfers. The resident's family reported the mistreatment to a nurse, who conducted a physical assessment and found no visible injuries. The nurse then asked the involved CNAs to provide written statements and reported the incident to the Director of Nursing (DON). However, the DON was on vacation at the time and did not address the investigation until her return. Interviews with the involved CNAs and the resident's roommate revealed that the resident did not initially verbalize any pain or injury at the time of the alleged incident. The CNAs denied the allegations, and the roommate did not witness any mistreatment. Despite this, the facility's failure to suspend the CNA immediately after the allegation was reported was a breach of their abuse policy, as confirmed by the DON and the Administrator, who both acknowledged the oversight.
Inaccurate MDS Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their use of bed rails, which are considered enablers. For Resident #5, the quarterly and annual Minimum Data Set (MDS) assessments did not accurately reflect the resident's use of bed rails. Despite the resident's care plan and physician's orders indicating the use of assist bars for bed mobility, the MDS assessments did not mark the use of bed rails. Interviews revealed that the MDS Coordinator did not consider bed rails as restraints and therefore did not code them in the MDS, despite the resident's inability to use them effectively due to physical limitations. Similarly, Resident #6's quarterly MDS assessment failed to reflect the use of bed rails, even though the resident's care plan and physician's orders indicated their use for bed mobility and positioning. The facility did not conduct any enabler assessments for Resident #6, and the MDS Coordinator stated that bed rails were not coded as they were considered enablers, not restraints. The Director of Nursing acknowledged that the MDS was inaccurate because it did not include the bed rails in Section P. The facility's policies on maintaining MDS assessments and documentation in medical records did not address the accuracy of MDS assessments. The lack of accurate documentation and assessment could potentially affect the care provided to residents who require bed rails for safety and mobility, as the facility did not ensure that the MDS accurately reflected the residents' needs and use of enablers.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bed rails as enablers for two residents, leading to a deficiency in care. Resident #5 and Resident #6 were not assessed for the risk of entrapment from bed rails prior to their installation, nor were the risks and benefits reviewed with the residents or their representatives. Additionally, informed consent was not obtained before the installation of the bed rails. This oversight was identified during observations, interviews, and record reviews conducted by surveyors. Resident #5, a male with a history of rheumatoid arthritis, diabetes mellitus, and muscle weakness, did not have a signed consent form for the use of bed rails. The resident required substantial assistance with activities of daily living and was unable to use the bed rails due to weakness in his hands and arms. Despite this, the facility had not conducted ongoing enabler assessments to determine the appropriateness of the bed rails for Resident #5's needs. Interviews with the physical therapist and the director of nursing revealed that no alternatives were attempted before the installation of the bed rails, and there was no physician's order for their use. Similarly, Resident #6, a female with muscle wasting, lack of coordination, and a history of falls, also lacked a signed consent form and had not undergone any enabler assessments. The resident's care plan indicated the use of grab bars to promote independence, but the facility failed to conduct ongoing assessments to ensure the bed rails were appropriate. The director of nursing acknowledged that the facility did not follow its policy of obtaining informed consent and conducting regular assessments, which could lead to the inappropriate use of enablers and increased risk of injury.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #9, which included measurable objectives and time frames to meet her medical and nursing needs. Resident #9, an elderly female with dementia, muscle weakness, and mobility issues, was assessed to be at risk for falls. Her care plan included the use of a fall mat next to her bed as a safety measure. However, during an observation, it was noted that the fall mat was not in place while the resident was lying in bed, as it was folded and positioned behind the headboard. Interviews with facility staff, including an LVN and a CNA, revealed that the fall mat was supposed to be used whenever Resident #9 was in bed, but it was forgotten on this occasion. The Director of Nursing confirmed that the fall mat was a necessary intervention listed in the resident's care plan to prevent falls. Despite the resident not having any recent falls, the failure to follow the care plan posed a risk of potential injury to the resident.
Failure to Post Oxygen Warning Signs for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed during a survey. A resident, who was on continuous oxygen therapy via nasal cannula, did not have the required oxygen warning signs posted outside his bedroom. This oversight was noted during an observation, and both a registered nurse and the Director of Nursing acknowledged the absence of the sign, which is intended to inform staff and visitors of the oxygen use for safety purposes. The facility's policy mandates that oxygen warning signs must be placed on the door of any resident's room where oxygen is in use. The resident in question was admitted with a diagnosis of pulmonary embolism and was at risk for respiratory infections and distress. The resident's care plan included continuous oxygen therapy to maintain oxygen saturation levels above 90%. Despite these requirements, the absence of the oxygen warning sign posed a risk of inadequate monitoring and potential harm due to unawareness of the oxygen use. The facility's policy also outlines the need for staff to monitor for complications associated with oxygen use, emphasizing the importance of adhering to safety protocols.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential errors in treatment and services. For one resident, the facility did not document the correct diet texture in the orders and care plan. The resident was admitted with a regular diet from the hospital, but the facility incorrectly documented a pureed texture diet. The Director of Nursing (DON) admitted to making a mistake in entering the order and acknowledged that the error was not addressed during the resident's stay. Interviews with staff indicated that the resident ate well and did not complain about the food. For the second resident, the facility failed to accurately document the administration of a nebulizer treatment in the Medication Administration Record. The record showed missing initials for several days, although the Licensed Vocational Nurse (LVN) responsible claimed the treatment was administered and suggested a computer glitch might be the cause. The DON reviewed the documentation and found no medication errors but emphasized the importance of accurate documentation to verify proper care and treatment. The facility's policy on medical record documentation requires that each resident's record accurately reflects their experiences and includes sufficient details about their care. The policy mandates that documentation be completed at the time of service or by the end of the shift. The deficiencies in documentation for both residents highlight a failure to adhere to these standards, potentially impacting the quality of care provided.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not administered these medications unless necessary to treat a specific condition, as diagnosed and documented in the clinical record. This deficiency was identified in two residents during a review for unnecessary medications. Resident #111 was prescribed Seroquel without an appropriate diagnosis, and Resident #274 was given Zyprexa PRN without an end date, both of which are antipsychotic medications. Resident #274, who was admitted with diagnoses of altered mental status and cognitive communication, had a physician's order for Seroquel without an indication for use. Additionally, Zyprexa was ordered PRN for acute manic episodes without an end date. The care plan for Resident #274 included goals to remain free of psychotropic drug-related complications, but the necessary documentation and indications for the medications were missing. The Director of Nursing (DON) acknowledged the oversight, stating that the indication for use and end date should have been documented during weekly psychotropic medication audits. Resident #111, who had a history of cerebral infarction, respiratory failure, and was unable to communicate, was prescribed Olanzapine for agitation without a proper diagnosis. The DON confirmed that antipsychotics like Olanzapine should not be used for agitation due to potential long-term side effects and that PRN orders should have a 14-day limit to ensure ongoing appropriateness. The facility's policy on psychotropic medication use requires documentation of specific conditions and non-pharmacological interventions before initiating such medications, which was not adhered to in these cases.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed multiple instances of improper food storage and handling that could lead to contamination. An open and unsealed bag of chips was found in the pantry, which the cook acknowledged could lead to contamination and potential health risks for residents. Additionally, a box of frozen vegetables was found on the floor of the walk-in freezer, which the dietary manager confirmed posed a risk of contamination. Further observations in the walk-in freezer showed a box of mini muffins soaked with water from condensation on the ceiling, which the dietary manager stated could lead to mold and bacterial growth. Inside the refrigerator, a container of jelly was not properly closed, and a chocolate dessert topping bottle had dry chocolate drippings. The cook and dietary manager both noted that these conditions could lead to bacterial growth and contamination of other food items stored nearby. Interviews with the Director of Nursing (DON) and the administrator confirmed that these practices were unacceptable and posed a risk of cross-contamination and bacterial growth. The facility's policy on food safety, which emphasizes the importance of storing food in a manner that prevents contamination, was not followed. The policy specifically requires that food be stored off the floor and in sealed containers to prevent deterioration and contamination.
Failure to Accommodate Resident's Call Light Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically regarding the accessibility and usability of the call light system. The resident, who had severe cognitive impairment and functional limitations due to a stroke and vascular dementia, was observed to have a call light that was not within reach and difficult to use. The call light was wedged between the side of the wheelchair and the wheel, lacking a securing device, and was not the type the resident was accustomed to using. The resident expressed difficulty in using the cylindrical call light and preferred a flat, round call light with a red cross, which he found easier to use. Interviews with the Director of Nursing (DON) and the Therapy Director revealed a lack of awareness and assessment regarding the resident's specific needs for a call light. The DON acknowledged the importance of having a call light within reach and suitable for the resident's use, but had not noticed the type of call light the resident had. The Therapy Director mentioned that recommendations for call light assessments could be made during IDT meetings, but no such recommendations had been made for this resident. The facility's policy required evaluation of each resident's unique needs for call light accessibility, but this was not effectively implemented for the resident in question.
Failure to Provide Range of Motion Therapy
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, which could potentially lead to decreased range of motion, decreased quality of life, and increased risk of contractures and threats to skin integrity. The resident, who had a history of cerebral infarction, tracheostomy, and feeding tube, was unable to speak or communicate needs and was totally dependent on others for activities of daily living. Despite having functional limitations in range of motion to his arms and legs, the resident did not have a care plan addressing these needs, and no restorative therapy was provided during the 7-day look-back period of the MDS assessment. The resident's physician's orders included evaluations and recommendations for physical, occupational, and speech therapies, but these services were discontinued due to a change in payment source. Interviews with the Director of Rehabilitation and the DON revealed that the facility did not have a restorative program to provide necessary therapeutic interventions, which posed risks such as contractures, increased muscle tone, and skin breakdown. The physical therapist noted that the resident had joint stiffness and would benefit from continued therapy, but no plans were in place to provide additional therapy services.
Inadequate Supervision and Improper Use of Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for two residents. For Resident #103, who has Alzheimer's disease and muscle weakness, the facility's staff did not follow proper transfer procedures. The resident's care plan required extensive assistance from two staff members using a gait belt for transfers. However, during an observation, CNA A and NA B transferred the resident from his wheelchair to the bed by grabbing him from his armpits and the back of his pants, which was not in accordance with the facility's policy. Both aides acknowledged that this method was unsafe but cited the resident's combative behavior as the reason for not using the gait belt. For Resident #15, who has a history of falls and severe impairment, the facility failed to ensure the proper placement of a fall mat. The resident's care plan indicated the use of a fall mat to prevent injury. However, during an observation, the fall mat was found away from the resident's bed, which could lead to potential injury if the resident attempted to get up unassisted. A family member noted that the resident frequently tried to get up without assistance, and the RN confirmed that the mat was not placed correctly. The facility's policies on fall prevention and safe resident handling were not adhered to in these cases. The policy required the use of gait belts for residents who cannot independently ambulate or transfer, and the safe handling policy emphasized the use of mechanical lifts and handling aids. Despite these policies, the staff did not use the gait belt for Resident #103, and the fall mat for Resident #15 was not positioned correctly, leading to potential risks for both residents.
Failure to Label Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not properly label the enteral feeding formula for Resident #111, which put the resident at risk of not receiving adequate nutrition. During an observation, it was noted that the plastic bottle containing the feeding formula was not labeled with any information about the resident, the rate of administration, or other necessary details. Resident #111, who was unable to speak or communicate needs, had a history of cerebral infarction, respiratory failure with hypoxia, and was dependent on a feeding tube for nutrition. The resident's care plan indicated the use of enteral feedings, and a physician's order specified the use of Jevity 1.2 at a rate of 70 ml per hour. However, an interview with LVN J revealed that she had forgotten to label the feeding bottle, which was against the facility's policy requiring labels to include the resident's name, room number, date changed, and the nurse's signature/initials.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to a deficiency in care. The resident, an elderly female with a history of altered mental status, dementia, anxiety, and cognitive communication deficit, was on oxygen therapy as per physician orders. The care plan specified the need for continuous oxygen via nasal cannula to prevent respiratory distress. However, during an observation, the resident was found with the nasal cannula under her chin, not in place as required, although the oxygen tank was not empty. Multiple staff members, including CNAs and an LVN, interacted with the resident without ensuring the nasal cannula was properly placed. CNA F entered the room to comb the resident's hair but did not adjust the nasal cannula. CNA G replaced the oxygen tank but also failed to reposition the nasal cannula. It was only when LVN H assessed the resident that the nasal cannula was placed correctly, resulting in an increase in the resident's oxygen saturation from 71% to 96%. The LVN noted that CNAs were responsible for checking the nasal cannula placement during their rounds. Interviews with the CNAs and the DON revealed that the staff had received training on oxygen therapy and were aware of the importance of ensuring the nasal cannula was in place. However, both CNAs admitted to neglecting this responsibility due to nervousness. The DON confirmed that CNAs and LVNs were expected to ensure proper oxygen therapy administration, including checking the nasal cannula placement during rounds. The facility's policy on oxygen administration emphasized adherence to physician orders and care plans, which was not followed in this instance.
Improper Disposal of Used Cooking Oil
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically regarding a barrel used for disposing of used cooking oil. Observations and interviews revealed that the barrel was left uncovered, nearly full, and contained trash and debris floating on the oil. The Dietary Manager (DM) acknowledged the risk of the uncovered barrel spilling and attracting pests, which could potentially affect the residents and staff by contaminating food from the kitchen. Further interviews with the maintenance director and the Director of Nursing (DON) confirmed the risks associated with the uncovered oil barrel. The maintenance director noted that the barrel should be closed with a lid to prevent overflow during rain and to avoid attracting pests. The DON expressed concerns about the potential health risks to residents due to the attraction of pests like roaches and flies. The facility's administrator also recognized the hazard posed by the exposed container, emphasizing the risk of insect attraction and potential spillage. Despite requests, the facility did not provide policies and procedures for proper storage and disposal of garbage and refuse by the time of the surveyor's exit.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a nursing assistant (NA B) who did not adhere to proper hand hygiene and glove-changing protocols during incontinent care for a resident. The resident, who was admitted with diagnoses including dementia and muscle wasting, was observed to be always incontinent of bladder and bowel. During the care procedure, NA B did not wash her hands before donning gloves and failed to change gloves after they became contaminated, which could lead to cross-contamination and the spread of infections. The incident was observed by a surveyor, and NA B admitted to forgetting the proper procedures due to nervousness. Despite having received training on infection control, NA B did not follow the expected protocols of washing hands before putting on gloves and changing gloves after contamination. The Assistant Director of Nursing (ADON) acknowledged the lapse and noted that she had not yet conducted infection control training for the staff, as she had recently started working at the facility. The Director of Nursing (DON) and the Administrator were informed of the incident and confirmed that the staff were expected to follow hand hygiene and glove-changing protocols to prevent infection spread. The facility's policies on incontinence care and personal protective equipment emphasize the importance of hand hygiene and appropriate use of gloves to prevent transmission of pathogens. However, the failure to adhere to these protocols during the observed incident highlights a deficiency in the facility's infection prevention and control program.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the stove, in safe operating condition. During an observation and interview, it was revealed that the oven on the right side of the stove was not functioning. The dietary manager (DM) reported the issue to maintenance and documented it in the work order log on 3/24/2024. Despite this, the oven remained unfixed, posing a risk of foodborne illnesses due to improper cooking temperatures. The maintenance director confirmed that the oven was essential for preparing meals for residents and acknowledged the potential risk of illness if food was not cooked properly. The maintenance director explained the process for reporting and addressing maintenance issues, which involved logging requests in a work order binder reviewed daily. He stated that the oven had been repaired multiple times, but continued to malfunction. The initial repair involved replacing parts, but the oven broke down again shortly after. Further inspection revealed a solenoid relay issue, and the necessary part was on backorder, delaying repairs for approximately three months. The maintenance director had not followed up on the status of the part until prompted by the surveyor. The administrator was aware of the ongoing issues with the oven and acknowledged the possibility of using a different vendor for repairs. However, no efforts were made to find an alternative vendor, as they were satisfied with the current service provider. The administrator did not consider the oven essential equipment and did not perceive a risk to residents from the non-functioning oven. The facility's policy on essential equipment was requested but not provided by the time of the survey exit.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) data to the CMS system within the required 14 days after the completion of a resident's assessment. This deficiency was identified for five residents who were reviewed for electronic transmission of MDS data. The residents involved had various medical conditions, including severe cognitive impairment, dementia, depression, psychotic disorder, Parkinson's Disease, Chronic Obstructive Pulmonary Disease, epilepsy, diabetes, seizure disorder, and lung cancer. The MDS data for these residents, including discharge and death assessments, were significantly overdue, with delays ranging from 76 to 101 days. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for transmitting the MDS data. MDS Nurse D indicated that the discharge MDS for one resident was pending transmission and should have been sent by MDS Nurse E. However, MDS Nurse E stated that she had consulted with the MDS corporate supervisor, who advised that the MDSs did not need modification and had been transmitted. Despite this, the CMS Submission Report confirmed that the MDS records were only transmitted on the day of the survey. The facility's policy required transmissions to be completed within 14 days of completion, which was not adhered to in these cases.
Resident Left Outside Overnight Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident who exited the building and was left outside overnight. The resident, who had a diagnosis of Parkinson's disease and moderate cognitive impairment, was able to exit the facility through a door in the bistro area. The resident was seen on video footage pushing the door open with his hands and feet while in a wheelchair and subsequently making his way outside. He was not discovered missing until the following morning when a nurse found him outside on the patio. The resident's care plan indicated he was an independent smoker and did not require supervision while smoking. However, the facility's failure to ensure the door alarm was activated allowed the resident to exit unnoticed. Additionally, the staff on duty did not conduct proper rounds or respond to reports of the resident's absence. A CNA reported the resident missing to the charge nurse twice during the night, but the charge nurse dismissed the concerns and continued with her tasks without verifying the resident's whereabouts. The incident was not documented in the facility's incident report log, and the resident was not accounted for during the night shift. The charge nurse was preoccupied with other tasks and did not conduct rounds or respond to the CNA's reports. The facility's lack of supervision and failure to ensure the door alarm was functioning placed the resident at risk of harm, although he did not sustain any injuries or express discomfort from the incident.
Failure to Provide Adequate Supervision and Maintain Safe Environment
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents. Specifically, Resident #8, who had a history of aggressive behavior and was on 1:1 supervision, was left unattended by the Lead CNA. The Lead CNA left Resident #8 to assist another staff member without ensuring another nursing staff member was available to supervise Resident #8. This lapse in supervision led to Resident #8 hitting another resident, Resident #9, who had multiple medical conditions including muscle weakness and diabetes mellitus. The incident occurred in the morning, and the Lead CNA admitted to leaving Resident #8 unattended for less than 10 minutes, during which the altercation took place. Additionally, the facility failed to keep the Employee Lounge door closed, which posed a potential risk to residents. The Housekeeper left the door open, despite a posted sign instructing that the door should remain closed at all times. The Housekeeping Manager and the DON acknowledged that residents could enter the lounge and consume food or drink that might not be safe for them, particularly for those with conditions like diabetes. The facility did not have a specific policy for keeping the Employee Lounge door closed, although there was a general policy for maintaining a safe environment and preventing accidents. Interviews with various staff members, including the Administrator, Lead CNA, and other nursing staff, confirmed the deficiencies in supervision and environmental safety. The Lead CNA was suspended pending investigation and later received training on 1:1 supervision. The facility's failure to provide adequate supervision and maintain a safe environment for residents was evident in both the incident involving Resident #8 and the open Employee Lounge door, which could have led to further accidents or harm to residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an overflowing trash can at the Hall 100 nurse station and a housekeeper not adhering to COVID-19 protocols. Observations revealed that the trash can was full and overflowing with various items, including fast food bags, paper towels, used gloves, and other debris on the ground. Interviews with the LVN and Housekeeping Manager indicated that the nursing staff were expected to manage the trash if it became overflowing before the housekeeper's scheduled time. The Director of Nursing (DON) confirmed that anyone seeing the trash overflowing was responsible for addressing it to prevent infection risks. Additionally, a housekeeper who felt sick did not follow the facility's COVID-19 policy by calling in before coming to work. The housekeeper exited the employee lounge without keeping the door closed, as required by a warning sign. The Housekeeping Manager and DON confirmed that the housekeeper had been trained on COVID-19 precautions and infection prevention control but failed to follow the protocol, which could risk spreading illness within the facility. The facility's Infection Prevention and Control Program policy mandates that all staff follow procedures to maintain a safe and sanitary environment.
Failure to Maintain Resident Dignity by Not Using Privacy Cover on Catheter Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's catheter bag had a privacy cover. Resident #2, who has severe cognitive impairment and multiple diagnoses including Dementia, Diabetes, and a Urinary Tract Infection, was observed on multiple occasions without a privacy cover on his catheter bag. The catheter bag was visible from the hallway and contained dark yellow-brownish urine, which compromised the resident's dignity and privacy. Interviews with the LVN and the DON confirmed that catheter bags should have privacy covers at all times to maintain residents' dignity and privacy. The facility's Catheter Care policy also mandates the use of privacy covers for catheter drainage bags. Despite this policy, Resident #2's catheter bag was observed without a privacy cover, and the privacy bag was found clipped to the back of the resident's wheelchair instead. This oversight indicates a failure to adhere to the facility's own policies and procedures, thereby compromising the resident's quality of life.
Failure to Coordinate PASRR Services for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to coordinate the assessment following the PASRR Completion PCSP for a resident with intellectual disabilities. The resident, who was PASRR positive, did not receive the necessary PASRR services because the facility did not submit a request to the state agency. This failure was attributed to the resident having out-of-state insurance, which the current state did not accept for PASRR services. The facility's administrator and MDS Coordinator were aware of the issue but did not take the necessary steps to ensure the resident received the required services. The resident, a female with a history of epilepsy, delusional disorders, traumatic brain injury, and seizures, was admitted and re-admitted to the facility. Despite being PASRR positive for intellectual and developmental disabilities, the resident did not receive the specialized services needed. The local mental health authority and the facility's staff acknowledged that the resident required PASRR services, but the out-of-state insurance issue prevented the provision of these services. The facility's records and interviews with staff revealed that no actions were taken to resolve the insurance issue or to submit a request for PASRR services to the state. Interviews with the facility's administrator, MDS Coordinator, and local mental health authority confirmed that the resident was not receiving PASRR services due to the insurance issue. The MDS Coordinator and local mental health authority both stated that the resident needed PASRR services to prevent a decline in health. Despite this, no steps were taken to address the issue, and the resident's care plan did not include the necessary PASRR services. The facility's failure to coordinate the assessment and provide the required services was a significant deficiency that could impact the resident's health and well-being.
Deficient Wound Care Practices
Penalty
Summary
The facility failed to provide necessary treatment and services based on comprehensive assessments and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for two residents. The Wound Care Nurse did not use gloves while handling gauze for Resident #6's right lateral foot wound, which was cleaned and left to air dry. The nurse admitted to the oversight and acknowledged the risk of infection due to not using gloves. The Director of Nursing (DON) confirmed that nurses are trained to use gloves during wound care to minimize infection risks, and the failure to do so could lead to contamination of wound care items and potential infection for the resident. For Resident #3, the Wound Care Nurse did not date or initial the patches after providing wound care for the resident's left hip surgical incisions. The nurse explained that she had lost her marker, which is why the patches were not labeled. The DON emphasized the importance of dating and initialing dressings and patches to ensure proper tracking of wound care and to identify who performed the treatment. The lack of labeling could result in uncertainty about when the dressing was changed and who conducted the wound care. The facility's Wound Treatment Management policy and Clean Dressing Change policy require evidence-based treatments and proper labeling of wound care supplies to prevent infection and ensure accurate tracking of wound care. The failure to adhere to these policies in the cases of Resident #6 and Resident #3 highlights deficiencies in the facility's wound care practices, potentially placing residents at risk for worsening pressure injuries and infection.
Failure to Submit PBJ Staffing Information
Penalty
Summary
The facility failed to follow guidelines for the mandatory submission of staffing information based on payroll data in a uniform format. Specifically, the facility did not submit the Payroll Based Journal (PBJ) staffing information to CMS for the 1st quarter of the fiscal year 2023 (October 1, 2022, to December 31, 2022). This failure was identified through a review of the facility's CMS reports and an email from the Corporate Administrator indicating that the PBJ submission had failed because CMS was no longer accepting submissions for that reporting quarter. The CASPER report also confirmed that no data was submitted for the quarter, triggering a deficiency. Interviews with the facility's Administrator and HR Coordinator revealed that the HR Coordinator was responsible for completing the PBJ and submitting it to the Corporate Administrator for review before it was sent to the state. The HR Coordinator stated that she had submitted the PBJ early to the Corporate Administrator but was unaware of what happened afterward. The Administrator admitted to not being familiar with the PBJ submission process and deferred to the HR Coordinator. This lack of proper submission could place residents at risk for unmet personal needs, decreased quality of care, and a decline in health status.
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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