Avir At Stephenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Stephenville, Texas.
- Location
- 1670 Lingleville Rd, Stephenville, Texas 76401
- CMS Provider Number
- 455744
- Inspections on file
- 34
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Avir At Stephenville during CMS and state inspections, most recent first.
A cognitively intact male resident with bipolar disorder was prescribed medroxyprogesterone acetate (Provera) 5 mg daily by an NP for sexual behaviors, despite no sexual behaviors being addressed in his care plan. The MAR showed he received two doses, and a nursing note documented he was started on Provera and paroxetine with general medication education, but there was no signed consent for Provera on file. The resident later reported he learned from an outside case manager that he had been prescribed a hormone without his knowledge, stated he had not signed consent and did not want medication for his sex drive, and interviews confirmed the psych physician had not ordered Provera and that the facility had no written consent policy available. The DON and ADON acknowledged responsibility for obtaining consents lay with the prescriber or the nurse taking the order, yet no consent form for Provera could be produced.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice care, but the facility failed to document hospice services in the care plan and did not maintain required hospice forms, such as the certificate of terminal illness and hospice election form. Communication between hospice and facility staff was verbal, with no documented evidence as required by policy.
Staff failed to follow infection control protocols during perineal care for two male residents with incontinence and complex medical histories. Observed deficiencies included reusing wipes, not retracting the foreskin for cleaning, and wiping from back to front, all contrary to facility policy and recent staff training. These actions placed residents at risk for infection.
Two residents reported unsanitary conditions in their rooms and bathrooms, including the presence of roaches and unsafe bathroom fixtures. One resident's bathroom had an unsteady sink and toilet, and both residents expressed distress over the roach infestation. The facility's pest control measures were documented, but issues persisted, and the administrator was unaware of the specific bathroom fixture problems.
The facility failed to ensure a safe environment by allowing the DON to bring a dog that bit a resident and acted aggressively towards another. The incidents were not reported, and the facility lacked a clear policy on staff pets, contributing to the deficiency.
The facility failed to protect two residents from verbal abuse by a CNA, who was witnessed yelling and slamming doors. Despite initial denials from the residents, they later confirmed the abuse, indicating a failure in the facility's abuse prevention measures. The facility did not follow its policies for reporting and investigating the incident, as the DON did not document interviews or conduct an investigation, and the incident was not reported to the state agency.
A facility failed to report an alleged verbal abuse incident involving two residents to state authorities within the required timeframe. An RN witnessed a CNA yelling and slamming a door on the residents, but the incident was not documented or thoroughly investigated by the DON. The residents, both with significant medical conditions, denied the allegations, and the CNA continued working without suspension, contrary to facility policy.
The facility failed to investigate allegations of verbal abuse by a CNA towards two residents, despite a report by an RN. The residents, both with moderate cognitive impairments, denied the allegations when interviewed by the DON. The facility did not follow its abuse investigation policy, which requires thorough documentation and suspension of the accused employee during the investigation.
A resident in a LTC facility did not receive IV antibiotics as ordered due to a failure to mix the medication properly. The central line dressing was not changed as required, and weekly lab tests were not conducted. These deficiencies in care placed the resident at risk of infection relapse and complications.
Two residents in a LTC facility experienced significant medication errors. One resident did not receive IV antibiotics as ordered due to improper mixing and labeling, while another missed multiple doses of Insulin Glargine. These errors were attributed to misunderstandings and poor adherence to protocols, placing residents at risk of complications.
The facility failed to develop comprehensive care plans for residents, leading to missed PASRR services and lack of ADL goals. Insulin was not administered as ordered for a resident, and central line dressings were not changed as documented, highlighting significant lapses in care and communication.
A facility failed to change and date a resident's oxygen tubing weekly as required, leading to a deficiency in respiratory care. The resident, with chronic respiratory failure, had nebulizer tubing that was not replaced according to the schedule. The DON acknowledged the oversight and the lack of a clear policy on tubing dating, contributing to the deficiency.
The facility failed to ensure timely physician visits for several residents, with two not seen every 30 days during the first 90 days post-admission, and four not seen every 60 days thereafter. Missing documentation for specific months highlighted this deficiency. Interviews with the DON and ADMN revealed awareness of the issue, attributing it to physicians not visiting as required. The facility's policy mandates visits every 30 days initially and every 60 days thereafter, which was not followed.
The facility failed to maintain adequate nursing staff levels, as evidenced by timesheet reviews and resident interviews. On several occasions, the facility did not meet the required direct care staff hours, leading to concerns about delayed care and insufficient response to resident needs. The DON and ADMN acknowledged staffing issues due to unexpected staff resignations and absences, which were not aligned with the facility's policy of maintaining adequate staffing.
The facility failed to store medications securely and in their original containers, as observed with three medication carts containing unlabeled pill cups with various medications, including narcotics. Staff interviews revealed pre-filling of pill cups due to workload, risking incorrect medication administration. The DON acknowledged this practice was against policy, which requires medications to be stored securely and in original packaging.
A resident with a stage 4 pressure wound was treated without the privacy curtain being pulled, compromising their dignity and privacy. The LVN acknowledged the oversight, and both the DON and ADON confirmed the importance of using the curtain to prevent exposure. The facility's policy on maintaining resident dignity and privacy was not followed.
A resident's privacy was compromised when staff failed to pull the privacy curtain during peri-care and a transfer using a Hoyer Lift. The resident, who is cognitively intact and requires assistance due to incontinence and lack of coordination, was exposed to potential embarrassment. Facility policy requires maintaining resident dignity and privacy, which was not adhered to in this instance.
A resident was transferred using a Hoyer lift without locking the lift's legs in the required position, despite staff training on proper use. The resident, who was cognitively intact and dependent on staff for transfers, was at risk due to this oversight. The CNA admitted to not locking the lift previously, and the ADON confirmed the importance of locking the brakes to prevent falls.
Two staff members failed to follow proper infection control protocols during peri-care for a resident, neglecting to change gloves and perform hand hygiene between tasks. The resident, who was incontinent and had conditions such as hypertension and diarrhea, was at risk due to these lapses. The staff cited nervousness and lack of supplies, while the DON and ADON acknowledged insufficient training and monitoring.
The facility failed to store medications in locked compartments and keep them in their original containers. Observations revealed loose pills in the Hall 3 and Hall 5 medication carts. Staff acknowledged the issue, citing hurried actions and lack of attention as causes. The facility's policy requires drugs to be stored securely and in their original packaging.
A facility failed to respect a resident's right to smoke, revoking his smoking privileges without attempting other safety measures. The resident, with severe cognitive impairment and a history of elopement, was denied the only activity he enjoyed, despite being assessed as safe to smoke under supervision.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment, resulting in inadequate supervision and care. The care plan lacked person-centered interventions and measurable objectives, particularly concerning smoking safety and elopement. Interviews with the DON and ADMN confirmed the care plan's deficiencies.
Failure to Obtain Informed Consent for Hormone Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact male resident was fully informed of, and consented to, a hormone medication (medroxyprogesterone acetate/Provera) prescribed for sexual behaviors before it was administered. The resident, with a diagnosis of bipolar disorder and a BIMS score of 15/15, had no sexual behaviors identified or addressed in his comprehensive care plan. Nonetheless, an NP entered an order for Provera 5 mg by mouth daily for sexual behaviors, and the MAR showed the resident received two doses on consecutive evenings. Review of the electronic medical record revealed no evidence of a signed consent for Provera using the required HHSC Form 3713 prior to administration. Progress notes showed that on the same date the Provera order was initiated, the psychiatric provider evaluated the resident for worsening depression and anxiety, discontinued escitalopram (Lexapro), and started paroxetine (Paxil). A subsequent nursing note documented that the resident was started on Provera and paroxetine, and that he was educated on his medications and given printed information at his request, but there was still no documented written consent for Provera. The psychiatric physician later confirmed he did not prescribe Provera, only discussed it briefly as a medication ordered by the NP, and stated that obtaining signed consents was the facility’s responsibility. Interviews with staff and the resident further demonstrated that the resident had not been informed in advance or given the opportunity to consent in writing to Provera before receiving it. The resident reported learning from an outside case manager that he had been prescribed a hormone without his knowledge and stated he had not signed a consent and did not want medication for his sex drive. The DON and ADON each stated that the prescriber or the nurse taking the order was responsible for obtaining signed consent, but the facility was unable to produce a signed consent form for Provera or a policy on obtaining written consent for medications. This sequence of events shows the resident received Provera without the required informed, written consent.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, there was no evidence in the resident's comprehensive care plan that hospice services were being provided, despite the resident being admitted to hospice care. The clinical records lacked required hospice documentation, including the certificate of terminal illness, hospice election form, and documentation of communication between the facility and the hospice provider. The resident in question had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, kidney disease, and a urinary tract infection. Interviews and record reviews revealed that communication between hospice staff and facility staff was conducted verbally, and required communication forms were not being completed as per facility policy. The Director of Nursing acknowledged that the necessary documentation was missing and that it was her responsibility to ensure these documents were present. Facility policy required collaboration with hospice representatives, documentation of communication, and maintenance of specific hospice-related forms, none of which were found in the resident's records.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the provision of incontinent care for three staff members observed. Specifically, staff did not follow proper perineal care procedures for two male residents who were always incontinent. During observations, one CNA reused wipes by folding them instead of using a new wipe for each stroke, and did not retract and clean the foreskin of an uncircumcised resident. Another instance involved staff cleaning from back to front rather than the required front to back method. These actions were contrary to the facility's perineal care policy, which specifies the use of the one wipe, one swipe technique and proper cleaning of the foreskin for uncircumcised males. The residents involved had significant medical histories, including severe cognitive impairment, hypertension, lack of coordination, diabetes mellitus, generalized edema, and peripheral vascular disease. Despite recent in-service training and documented competencies indicating that staff had met pericare skills, the observed failures in technique placed residents at risk for infection. Interviews with the DON confirmed that the observed practices did not align with facility policy and could have led to infection, particularly due to improper cleaning of the foreskin and incorrect wiping technique.
Deficiency in Resident Rights Due to Unsanitary Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in resident rights. Resident #8's bathroom was found to be unsafe and unsanitary, with a sink that was unsteady and appeared to be pulling away from the wall, and a toilet that was unsteady at its base. The bathroom floor was covered in a yellow substance with dirt and fuzz, and a dead roach was observed under the sink. Resident #8 expressed concerns about the safety of the bathroom fixtures, fearing potential injury due to their instability. Both Resident #8 and Resident #10 reported issues with roaches in their rooms and bathrooms. Resident #10 described seeing large roaches in her room and bathroom, which caused her distress due to her upbringing associating roaches with uncleanliness. Resident #8 also reported seeing cockroaches in his bathroom, particularly at night, which added to his discomfort and dissatisfaction with the living conditions. The facility's pest control service log indicated that the facility had been serviced for roaches, spiders, and beetles, but the presence of roaches persisted, as reported by the residents. The administrator was unaware of the specific issues with Resident #8's bathroom fixtures and acknowledged the need for a more secure mounting solution for the sink. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which includes maintaining a clean and safe environment.
Unsafe Environment Due to Staff Pet in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the Director of Nursing (DON) bringing a dog to the facility, which resulted in incidents involving two residents. The dog bit one resident on the ankle and exhibited aggressive behavior towards another resident. These incidents were not reported immediately, and the facility lacked a clear policy regarding staff bringing pets to work, contributing to the deficiency. Resident #7, a female with a history of major depressive disorder, chronic obstructive pulmonary disease, and dysphagia, was bitten on the ankle by the DON's dog. The bite broke the skin, but the resident did not report the incident to avoid causing trouble. Resident #8, a male with a history of acute upper respiratory infection, spinal cord injury, and heart failure, experienced aggressive behavior from the dog while sitting on his scooter. He was not afraid of dogs but was concerned about the safety of other residents. Interviews with staff and residents revealed that the dog had been brought to the facility multiple times and had interacted with residents and staff, sometimes aggressively. The facility's existing dog policy did not adequately address situations involving staff pets, and there was no signed agreement from the DON regarding the facility's dog policy. The lack of a comprehensive policy and failure to report incidents contributed to the unsafe environment.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA D. The incident occurred on July 4, 2024, when CNA D was witnessed by a Registered Nurse (RN C) yelling, screaming, and slamming the door in the presence of the residents. Despite the allegations, the Director of Nursing (DON) did not report the incident to the Health and Human Services Commission (HHSC) Regulatory because the residents denied the abuse when interviewed by the DON. However, the residents later expressed nervousness and confirmed that CNA D yelled at them, indicating a failure in the facility's abuse prevention measures. The residents involved were both females with significant medical conditions. Resident #4, a female with ataxic cerebral palsy, anxiety disorder, and dysphagia, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Resident #5, also a female, had cerebral palsy and Parkinsonism, with a BIMS score reflecting moderate cognitive impairment as well. During interviews, both residents expressed fear and nervousness about being yelled at by CNA D, although they initially denied the allegations to the DON. The facility's response to the incident was inadequate, as the DON did not document interviews with the residents or witnesses, nor was an investigation conducted. The facility's policies on abuse prevention and reporting were not followed, as the incident was not reported to the state agency, and the accused CNA was not removed from duty pending an investigation. The lack of documentation and failure to conduct a thorough investigation highlight significant lapses in the facility's handling of abuse allegations.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to report alleged abuse incidents involving two residents to the appropriate authorities within the required timeframe. Specifically, an incident of verbal abuse was witnessed by an RN, who reported that a CNA yelled at and slammed the door on two residents. Despite the RN's immediate report to the Director of Nursing (DON) and the Administrator, the incident was not reported to the Health and Human Services Commission State Survey Agency or other officials as required by state law. The residents involved were both females with significant medical conditions, including cerebral palsy and cognitive impairments, as indicated by their BIMS scores. The DON conducted interviews with the residents, who denied the allegations, and with the CNA, who also denied the incident. However, the DON did not document the incident, conduct a thorough investigation, or interview the RN who reported the abuse. The CNA continued to work on the floor without suspension, contrary to the facility's policy. The facility's policies on abuse prevention and reporting were not followed, as the incident was not thoroughly investigated or reported to state agencies. The facility's policy requires immediate reporting of suspected abuse to the Administrator or DON, and the suspension of the accused employee until the investigation is complete. These procedures were not adhered to, resulting in a deficiency in handling the abuse allegation.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents, Resident #4 and Resident #5, by a Certified Nursing Assistant (CNA D) on July 4, 2024. The incident was witnessed by a Registered Nurse (RN C), who reported that CNA D entered the residents' room, yelled at them in a loud and irritated tone, and slammed the door. Despite RN C's immediate report to the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), no comprehensive investigation was conducted, and CNA D continued to work on the floor. Resident #4, a female with moderate cognitive impairment and multiple diagnoses including ataxic cerebral palsy and anxiety disorder, and Resident #5, a female with cerebral palsy and Parkinsonism, were both interviewed by the DON following the incident. Both residents denied the allegations of verbal abuse. The DON reported the incident to the Administrator but did not document the incident or conduct further interviews with RN C or other potential witnesses, as required by the facility's abuse investigation policy. The facility's policies on preventing resident abuse and conducting abuse investigations were not followed. The policy mandates that all reports of abuse be promptly and thoroughly investigated, including interviewing the person reporting the incident, witnesses, and other staff members. Additionally, the accused employee should be suspended pending the investigation's outcome. However, these procedures were not adhered to, as evidenced by the lack of documentation and the failure to remove CNA D from duty during the investigation.
Failure in IV Antibiotic Administration and Central Line Care
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids and antibiotics for a resident, leading to a deficiency in care. The resident, a female with a history of methicillin-resistant Staphylococcus aureus infection and recent knee surgery, was receiving IV antibiotics through a central line. The facility did not adhere to professional standards and physician orders, as evidenced by the failure to mix the antibiotic medication properly before administration. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not activate the vial containing the antibiotic powder, resulting in the resident not receiving the prescribed dose. Additionally, the facility did not change the resident's central line dressing as ordered by the physician. The dressing was observed to be loose and not sealed, which compromised the sterile environment necessary to prevent infection. The Director of Nursing (DON) acknowledged that the dressing should have been changed every seven days or as needed, but it had not been changed since a specific date. This oversight was attributed to a lack of communication and verification among the nursing staff, as one nurse assumed another had completed the task. Furthermore, the facility failed to draw the required laboratory tests weekly as ordered by the physician while the resident was on IV antibiotics. The lack of lab work monitoring could have impacted the resident's treatment and recovery. The DON admitted that the facility had not performed the necessary lab draws and was unaware of the oversight until contacted by the infectious disease physician's office. This deficiency in care placed the resident at risk of infection relapse and potential complications from untreated conditions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were reviewed for medication errors. Resident #7 did not receive her IV antibiotics as ordered by the physician on multiple occasions. The medication, meropenem, was not properly mixed before administration, resulting in the resident not receiving the antibiotic doses as prescribed. This failure was attributed to a misunderstanding by the nursing staff, who believed the medication was pre-mixed, and a lack of proper labeling and monitoring of the IV administration process. Additionally, the central line dressing for Resident #7 was not maintained properly, which could have increased the risk of infection. Resident #51 also experienced medication errors, with multiple instances of missed Insulin Glargine doses by various nursing staff members over a two-month period. These omissions were not in accordance with the physician's orders and placed the resident at risk of diabetic complications. The report highlights the lack of adherence to medication administration protocols and the failure to ensure that treatments were performed and documented accurately. The deficiencies in medication administration and documentation were observed through interviews and record reviews, revealing a pattern of non-compliance with established protocols. The facility's staff, including the DON and various LVNs, acknowledged the errors and provided explanations for the lapses, such as being busy or assuming tasks were completed by others. However, these explanations did not mitigate the fact that the residents were placed at risk due to the facility's failure to administer medications as ordered and maintain proper documentation and monitoring practices.
Deficiencies in Care Planning and Medication Administration
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which led to deficiencies in meeting their medical, nursing, and psychosocial needs. For Resident #2, the facility did not incorporate PASRR services into the care plan, despite the resident being PASRR positive. Resident #28's care plan lacked specific goals related to activities of daily living (ADL) functions, which are crucial for ensuring appropriate care and support. These omissions indicate a lack of thoroughness in the care planning process, potentially affecting the quality of care provided to these residents. Resident #51 experienced multiple instances where insulin glargine was not administered as per physician orders. Several licensed vocational nurses (LVNs) and a registered nurse (RN) failed to administer the insulin on numerous occasions over a two-month period. The nurses did not contact the physician to discuss holding or adjusting the insulin dosage, which is a critical step in ensuring proper diabetes management. This lack of communication and adherence to physician orders could have significant implications for the resident's health, particularly in managing blood glucose levels. Additionally, the facility failed to ensure that central line dressings for Resident #7 were changed as documented. LVNs B and C signed off on dressing changes that were not performed, citing distractions and assumptions that another nurse had completed the task. This oversight in documentation and execution of care tasks highlights a breakdown in the facility's processes for ensuring accurate and timely care. The failure to perform these essential tasks could lead to increased risk of infection and other complications for the resident.
Failure to Change and Date Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in changing and dating the oxygen tubing weekly as required. Resident #70, a female with chronic respiratory failure and other health issues, was observed to have nebulizer tubing dated 05/06/2024, indicating it had not been changed in accordance with the order to replace it every Sunday. This oversight was confirmed during an observation with the Director of Nursing (DON), who acknowledged that the tubing should have been changed and that the staff should not have dated the tubing per policy. The DON admitted to not knowing who was responsible for monitoring the tubing changes and mentioned that the interdisciplinary team should have been making rounds to ensure compliance. The lack of a clear policy on dating the tubing and the failure to follow the electronic medication administration record (EMAR) contributed to the deficiency. The facility did not provide evidence of a policy requiring the dating of respiratory tubing when changed, which could potentially place residents at risk of respiratory infections.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted as required for several residents. Specifically, two residents were not seen by a physician every 30 days during the first 90 days after admission, and four residents were not seen every 60 days thereafter. This lack of compliance with physician visit schedules was identified through interviews and record reviews, which revealed missing documentation for specific months when the visits should have occurred. Resident #2, a male with multiple diagnoses including hypertension, type 2 diabetes, and paranoid schizophrenia, was not seen by a physician in April 2024, despite the requirement for monthly visits during the initial 90 days post-admission. Similarly, Resident #73, diagnosed with Alzheimer's disease and acute kidney failure, missed physician visits in March, April, and May 2024. Other residents, such as Resident #25, #46, #51, and #56, also had gaps in their required 60-day physician visits, with missing documentation for various months in 2023 and 2024. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the facility was aware of the issue with timely physician visits. The DON acknowledged the responsibility for monitoring these visits and noted that the failure was due to physicians not visiting residents as required. The ADMN also recognized the problem and stated that the DON was working on improving the tracking system for physician visits. The facility's policy mandates physician visits every 30 days for the first 90 days and every 60 days thereafter, which was not adhered to in these cases.
Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by a review of timesheets and interviews with residents and staff. On three specific days, the facility did not meet the required direct care staff hours as per their PPD budget, with significant shortfalls noted. Interviews with residents revealed concerns about long wait times for care, such as waiting an hour to be changed, insufficient showers, and fears of inadequate response in case of falls. Staff interviews indicated a reluctance to discuss staffing issues due to fear of retaliation, and some staff expressed relief at the presence of state surveyors, hoping it would lead to better staffing. The Director of Nursing (DON) and Administrator (ADMN) acknowledged the staffing issues, attributing them to unexpected staff resignations, call-ins, and no-shows. The DON outlined expectations for staffing levels, which were not met, leading to potential risks such as increased falls and delayed care. The facility's policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved, as confirmed by the facility's own records and staff admissions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and maintain them in their original containers, as observed during a survey. Specifically, three medication carts were found with unlabeled pill cups containing various medications, including narcotics, outside of their original blister pack containers. These medications were not stored behind two locks as required, posing a risk of drug diversion. RN K was observed with seven unlabeled pill cups on top of medication cart #1, and three unlabeled pill cups containing narcotics inside an unlocked drawer. Similarly, RN J's medication cart #2 had unnamed pill cups with crushed medications, and cart #3 had an unlabeled pill cup with medication outside its original container. Interviews with staff revealed that RN J was pre-filling pill cups due to being busy and covering multiple halls, which could lead to administering the wrong medication to residents. The Director of Nursing (DON) acknowledged that pre-popping medications was against facility policy and could have detrimental effects on residents. The DON and Administrator emphasized the importance of following policies and proper medication disposal if refused by residents. The facility's policy from 2007 mandates that drugs and biologicals be stored in their original packaging and in a secure manner, which was not adhered to in this instance.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during wound care, as observed by surveyors. The incident involved a resident with a stage 4 pressure wound who was receiving treatment without the privacy curtain being pulled, despite the door being closed. This oversight was acknowledged by the LVN performing the care, who admitted that the curtain should have been closed to prevent exposure if someone entered the room. The resident expressed a preference for the curtain to be pulled to avoid embarrassment. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the privacy curtain should have been used to ensure the resident's dignity and privacy. Both the DON and ADON emphasized the importance of privacy during care and acknowledged that the failure to pull the curtain could lead to embarrassment for the resident. The facility's policy on dignity and respect, which mandates the protection of resident privacy during personal care, was not adhered to in this instance.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident during personal care activities. Specifically, staff did not pull the privacy curtain while performing peri-care and transferring the resident from bed to chair using a Hoyer Lift. This oversight was observed during a specific incident where another CNA entered the room without the curtain being drawn, compromising the resident's privacy. The resident involved was a cognitively intact male with a history of hypertension, lack of coordination, and incontinence. The facility's policy mandates that residents be treated with dignity and respect, including maintaining bodily privacy during personal care. Interviews with the ADON and DON confirmed that the failure to pull the privacy curtain was a breach of expected standards, potentially leading to embarrassment for the resident.
Failure to Lock Hoyer Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, during a transfer of a resident using a Hoyer lift, the CNA and NA did not lock the lift's legs in the maximum opened/locked position as required. This oversight occurred while transferring a cognitively intact male resident with a BIMS score of 15, who was dependent on staff for all efforts in activities such as chair/bed-to-chair transfers. The resident's diagnoses included hypertension, lack of coordination, and incontinence. During an observation, it was noted that the CNA did not lock the Hoyer lift during the transfer, and in an interview, the CNA admitted to not having locked the lift previously. The ADON confirmed that all nursing staff were trained on the use of the Hoyer lift and that the brakes should have been applied to prevent potential falls. The ADON also mentioned that the failure occurred because the CNA did not take the time to calm herself while being observed. The facility's records showed that the CNA had received training on the equipment, including the requirement to lock the wheels, but this was not adhered to during the incident.
Inadequate Infection Control During Peri-Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper peri-care and hand hygiene practices observed among two staff members, CNA L and an NA, during the care of Resident #28. The resident, a cognitively intact male with diagnoses including hypertension, lack of coordination, and diarrhea, was always incontinent. During an observation, the staff members did not perform hand hygiene or change gloves between dirty and clean tasks while providing peri-care, which is a violation of the facility's infection control protocols. Interviews with the staff revealed that CNA L was aware of the lapse in protocol but cited nervousness and lack of supplies as reasons for the oversight. The DON and ADON acknowledged the failure in ensuring staff adherence to infection control protocols, attributing it to inadequate in-service training and monitoring. The facility's policy on standard precautions mandates frequent hand washing and glove changes to prevent contamination, which was not followed in this instance, placing residents at risk of infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and to keep each resident's drugs in their original containers/packaging. During an observation, the Hall 3 medication cart was found to have seven loose pills in the second drawer, identified as Lisinopril, Midodrine, Furosemide, Keppra, Zoloft, and Buspirone. LVN B acknowledged the presence of loose pills and stated that staff sometimes get in a hurry, accidentally drop pills, and forget to dispose of them. LVN B also mentioned that all staff were responsible for ensuring their medication carts were clean, organized, and free from any loose pills. Similarly, the Hall 5 medication cart was observed to have three loose pills, identified as Atorvastatin, a Multi-vitamin, and Protonic. The ADON confirmed that there should not be loose pills in the medication carts and stated that every night shift was responsible for cleaning the medication carts, with every shift nurse also expected to clean the carts themselves. The ADON and DON both stated that they randomly checked medication carts at least once per week. The DON emphasized that the night shift was to check medication carts once per week and that staff should be aware and check each shift. The facility's policy on medication storage, dated April 2007, requires that all drugs and biologicals be stored in a safe, secure, and orderly manner in their original packaging or containers.
Failure to Respect Resident's Right to Smoke
Penalty
Summary
The facility failed to treat a resident with respect, dignity, and care in a manner that promotes the maintenance or enhancement of his quality of life. Specifically, the facility did not allow Resident #1 to smoke as per his request and smoking assessment. Resident #1, a male with severe cognitive impairment and a history of elopement attempts, had his smoking privileges revoked indefinitely after an elopement incident. The decision to revoke smoking privileges was made without attempting other measures to ensure his safety while allowing him to smoke, such as one-on-one supervision or allowing him to smoke in a secure courtyard. Interviews with staff and the resident's family member revealed that the facility's decision to revoke smoking privileges was intended for the resident's safety but was perceived as punitive. The family member expressed that smoking was the only activity the resident still enjoyed and that he could smoke safely. The Director of Nursing acknowledged that the care plan appeared punitive and admitted that no other measures were attempted to balance the resident's safety and his right to smoke. The facility's policy on resident rights emphasizes treating residents with respect, kindness, and dignity, which was not upheld in this case.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident that included measurable objectives and person-centered interventions specific to smoking safety and elopement. The resident, a male with severe cognitive impairment and multiple diagnoses including nicotine dependence and major depressive disorder, had a history of elopement attempts. Despite these incidents, the care plan did not include individualized and measurable goals to address these behaviors effectively. The resident's care plan was found to be lacking in person-centered approaches and measurable objectives. For instance, after an elopement incident, the care plan included general actions such as moving the resident to a different room and conducting window audits, but it did not provide specific, individualized interventions. Additionally, the care plan failed to address the resident's smoking needs adequately, as it only mentioned the revocation of smoking privileges without considering alternative solutions like nicotine patches. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the care plans were not person-centered and lacked measurable objectives. The DON acknowledged that the care plan should have included different approaches and not just the suspension of smoking privileges. The ADMN also stated that the care plans should have been person-centered and that the failure to do so could result in residents not having all their needs met. The oversight in creating a comprehensive, individualized care plan led to the deficiency in providing appropriate supervision and care for the resident.
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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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