Avir At Tierra Este
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 14300 Pebble Hills Blvd, El Paso, Texas 79938
- CMS Provider Number
- 745038
- Inspections on file
- 19
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Avir At Tierra Este during CMS and state inspections, most recent first.
Dietary staff failed to follow hand hygiene practices during meal service, including handling a cell phone, propping a door open with a can placed on the floor, and then immediately resuming food tray handling without washing or sanitizing hands. The staff member also provided tray covers and additional food items to an LVN and continued working the tray line before later returning with gloves on, with no confirmation that hand hygiene was performed before donning them. Facility leadership and another dietary staff member reported that staff are trained and expected to wash hands before handling food trays and after touching non-food items, in accordance with the facility’s hand hygiene policy.
A resident with severe cognitive impairment, dysphagia, renal failure, and a documented history of dehydration and related hospitalizations did not have a comprehensive, person-centered care plan addressing dehydration, despite facility policy requiring such plans. Record review showed no specific dehydration diagnosis order and no dehydration-focused care plan, only a generic "risk for altered fluid balance" plan with limited interventions. The DON and Administrator acknowledged that the care plan lacked content on dehydration prevention, while the MDS nurse stated that existing fluid balance interventions were being used, even though they did not specifically address the resident’s dehydration diagnosis.
The facility did not have a full-time DON for an extended period after the previous DON resigned, as confirmed by staff timecards and interviews with the ADON, HR, and the Administrator. During this time, coverage was provided by an LVN ADON, a PRN RN, and a Regional Clinical Support Specialist, but no full-time or interim DON was designated.
A resident with a stage 4 pressure ulcer did not receive wound care consistent with physician orders, as the wound vac was set at 125mmHg instead of the prescribed 115mmHg. The DON admitted to not checking the settings during care, acknowledging the risk of increased bleeding. Despite the incorrect setting, the resident reported no discomfort, and observations showed no signs of infection. The facility lacked a specific policy for wound vac management.
A resident with an indwelling catheter was found with the catheter bag touching the floor, contrary to facility policy, which requires bags to be hung to prevent infection. Despite the facility's guidelines, staff interviews revealed a lack of adherence to proper catheter care procedures, posing a risk of contamination and infection.
The facility failed to provide a safe and clean environment due to insufficient housekeeping staff, leading to unclean conditions and safety hazards. Observations included unclean floors, full sharps containers, water leaks, and inadequate safety measures during cleaning. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness and safety.
The facility exhibited several environmental deficiencies, including dusty and stained floors, water leaks from a condensation pipe, and inadequate housekeeping practices. Observations revealed that caution signs were not always adhered to, and there was a lack of sufficient signage during mopping. Additionally, debris such as a dead cricket and white tablets were found in the hallways, compromising the residents' right to a safe and clean environment.
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies. A resident's Voltaren Gel order lacked a dosage, leading to incorrect application. Another resident's refusal to take Lactulose was not reported, causing a missed dose. Additionally, a resident did not receive Zinc Sulfate due to supply issues. Staff also failed to follow controlled substance protocols, signing audit records before completing required counts.
The facility failed to ensure appropriate use of psychotropic medications for several residents, leading to unnecessary administration of antipsychotics without proper diagnoses or documentation. Residents were given medications like Risperidone, Aripiprazole, and Olanzapine without attempts at gradual dose reductions or documented clinical contraindications. Additionally, some residents were prescribed psychotropic medications without a 14-day stop date, violating facility policy.
The facility experienced a 22% medication error rate due to Med Aide E's failure to administer medications correctly to two residents. One resident choked on a capsule that should have been crushed, and another did not receive critical medications due to unavailability. The facility's protocols for medication administration and reporting were not followed, contributing to these deficiencies.
The facility failed to ensure proper storage and security of medications, with issues such as dried drippings on bottles, improper storage by administration route, and unlocked medication carts. Additionally, opened Acidophilus Probiotic Dietary Supplements were not refrigerated as required. These deficiencies were confirmed through staff interviews and observations.
The facility failed to prepare instant mashed potatoes according to the manufacturer's serving chart, impacting the nutritional value of meals for 16 residents on pureed diets. A staff member estimated the amount of water and potato flakes needed, rather than following the exact instructions. The Dietary Manager confirmed the requirement to follow manufacturer directions, but the Dietary Supervisor was unaware of the concern.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including unclean food preparation areas, improper food storage, and inadequate dishwashing procedures. The lack of supervision and oversight, exacerbated by the absence of a dietary manager, contributed to these issues, potentially putting residents at risk of foodborne illnesses.
The facility's kitchen had multiple sanitation and storage deficiencies, including food particles and stains on surfaces, improper storage of food items, and undated or improperly sealed food in refrigerators. The Dietary Manager lacked written cleaning assignments, and staff did not follow manufacturer directions for pureed foods. Observations revealed issues with cleanliness and food storage practices.
The facility did not ensure the Medical Director or a representative attended 5 out of 9 QAPI meetings reviewed, as required by policy. The absence of the Medical Director from these meetings could lead to unidentified quality deficiencies and lack of appropriate action plans.
The facility failed to maintain an effective infection prevention and control program, with issues such as unsealed dirty linen hampers, improperly stored gauze sponges, mattresses on the floor, and personal items in clean linen closets. These practices were observed across multiple halls and were contrary to the facility's infection control policies.
A resident with moderate cognitive impairment and bladder dysfunction was found with an uncovered urinary catheter bag, violating their privacy. Facility staff, including the RN and DON, acknowledged the oversight, which contradicted the facility's policy requiring catheter bags to be covered to maintain resident dignity.
A facility failed to accommodate a resident's monitoring preferences by obstructing an electronic camera placed by the family to monitor care. Despite the family's request to keep the camera unobstructed, staff were instructed to block it during care to protect the resident's privacy. The facility's policy states that obstructing a monitoring device is a misdemeanor, yet the practice continued, prioritizing privacy over the family's monitoring needs.
Two residents in the facility did not receive their prescribed medications due to unavailability and dosage errors. One resident with multiple health issues did not receive several medications as they were not stocked, and the physician was not notified. Another resident had a medication order without a specified dosage, and the physician was not informed to correct this. The facility's policies on medication unavailability and notification of changes were not followed, leading to potential delays in medical treatment.
A resident and their family raised privacy concerns about the use of cameras in the resident's room, leading to actions such as covering the camera for privacy. The DON instructed staff to block cameras, citing dignity concerns. There was confusion about the use of the TV and lights at night, and the camera's placement raised a potential fire concern. The family expressed uncertainty about the care provided, highlighting a balance issue between resident privacy and family rights.
A facility failed to conduct a required PASARR screening for a resident after a new diagnosis of schizophrenia was added to her records. Despite the facility's policy requiring evaluations for serious mental illnesses, the oversight was acknowledged by staff, including the MDS Nurse and DON, who noted the importance of rescreening to ensure residents receive necessary services.
A facility failed to ensure proper wound care for a resident with an LVAD by not dating the dressing and allowing drainage onto the resident's gown, increasing infection risk. Despite physician's orders for regular dressing changes and antibiotics, the dressing was found undated and soiled. Interviews with staff confirmed that the dressing should have been dated and changed as needed, highlighting a lapse in adherence to care protocols.
A resident requiring continuous oxygen therapy was found without her nasal cannula, which was uncovered and not in use, posing an infection risk. Additionally, oxygen cylinders were improperly stored in a scale room without appropriate signage, contrary to facility policy.
A facility failed to ensure timely physician response to a Pharmacist Consultant's recommendation regarding a resident's medication regimen. The resident, with multiple health conditions, was on iron sulfate therapy, and the pharmacist advised evaluating its necessity beyond eight weeks. The recommendation was not acted upon promptly due to the absence of a system to ensure timely physician action.
A facility failed to maintain proper communication and coordination with a dialysis center for a resident with end-stage renal failure. The resident's care plan lacked directives for communication, and dialysis communication forms were often incomplete. Staff interviews revealed a lack of awareness and follow-up on these discrepancies, and the facility's hemodialysis policy was not adhered to, posing a risk of missing changes in the resident's condition.
A facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and incident reporting. An allegation by a resident of being called 'stupid' and handled roughly by a CNA during ADLs was not documented, nor was an incident report completed. Additionally, a resident-to-resident altercation was not accurately documented, and no incident report was filed. These oversights were confirmed through staff interviews, revealing a lack of adherence to the facility's policy on incident reporting.
A facility failed to repair a broken window in a resident's room, compromising the safety and comfort of residents who were on oxygen therapy. The broken window, covered with cardboard and plastic, allowed dust and air to enter, affecting residents' respiratory health. Despite multiple reports and follow-ups, the window remained unfixed for several months due to delays in ordering a replacement.
The facility failed to conduct a criminal background check on the Administrator before she began her duties, contrary to its policies on preventing abuse. The Administrator started working without a completed background check, which was only done after an HR audit. Interviews revealed inconsistencies in the background check process, with no documentation from corporate confirming a check was done prior to her start date.
A facility failed to report an altercation between two residents, where one allegedly hit the other with a cane. Despite staff awareness and documentation of the incident, it was not reported to the necessary authorities as required by state law. The facility's corporate office deemed the incident non-reportable due to insufficient evidence, contrary to the facility's policy.
A facility failed to provide necessary treatment and services for a resident with venous ulcers, as dressings were not dated or initialed, and edges were peeling off. Despite orders for wound care three times a week, discrepancies in care frequency were noted. Staff interviews revealed a lack of adherence to standard procedures, posing a risk of infection.
The facility failed to complete a comprehensive facility-wide assessment, including a staffing plan, necessary for competent resident care during regular operations and emergencies. The assessment was overdue, and the Director of Nursing had not finished her section on staffing. The Administrator acknowledged being out of compliance with the annual assessment policy, attributing the delay to issues with a previous interim DON.
Failure to Ensure Proper Hand Hygiene During Food Handling and Tray Service
Penalty
Summary
The deficiency involves a failure to maintain sanitary food service practices by not ensuring proper hand hygiene by dietary staff during food handling and meal service. During a lunch observation, a dietary staff member used her cell phone immediately before beginning to place resident lunch trays onto carts and did not perform hand hygiene between handling the phone and handling the trays. After placing several trays on a cart, she was asked by an LVN to prop open a door; she picked up a food can, placed it on the floor to hold the door open, and then returned directly to the food line and continued placing food trays on carts without washing or sanitizing her hands. Further observation showed that the same dietary staff member continued to handle food service items without hand hygiene. She provided tray covers with both hands, handed salsa and ground chicken to an LVN, and resumed placing trays on the food cart, all without observed handwashing or sanitizing. She later left the food line and returned wearing gloves, but it was not known whether she had performed hand hygiene before donning the gloves. In interviews, the dietary manager, DON, and administrator each stated that staff are expected to wash their hands before handling food trays and after touching non-food items or moving between tasks, and that the observed conduct did not comply with facility expectations. Another dietary staff member reported that he consistently practiced proper hand hygiene and that the facility trains staff, including new hires, to wash or sanitize hands immediately after touching anything outside the food tray line. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and that all personnel are expected to adhere to these practices.
Failure to Develop Person-Centered Dehydration Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a failure by the facility to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with a medical history of dehydration. The resident, an elderly female with diagnoses including type 2 diabetes with hyperglycemia, dehydration, acute kidney failure, TIAs, hyperlipidemia, dysphagia, and renal failure, had been admitted and later readmitted to the facility. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and physical impairments in one upper extremity and both lower extremities. Despite this history and a hospital history and physical documenting dehydration, the facility did not have a specific care plan addressing dehydration. Record review showed that the resident’s care plan dated 01/15/2026 did not include any problem, goal, or interventions related to her medical diagnosis of dehydration. The Physician’s Order Summary also did not contain an order for maintaining the medical diagnosis of dehydration. The DON acknowledged during interview that the resident’s care plans contained nothing regarding dehydration or how to prevent it, and stated that the risk of having no care plan for dehydration would be that the resident could dehydrate again and be readmitted to the hospital. The Administrator similarly stated that, given the resident’s medical diagnosis of dehydration and history of hospitalization for dehydration and UTIs, there should have been a care plan. The MDS nurse reported that care plans are developed on admission, quarterly, and with any change in condition, and that nursing staff share responsibility for reviewing care plans and ensuring they are correctly entered into the electronic system. The MDS nurse stated there was no specific order for the resident’s medical diagnosis of dehydration, but asserted there was no risk because a care plan for “risk for altered fluid balance” existed, with interventions such as evaluating blood pressure and educating the resident/representative on methods to relieve dry mouth while maintaining fluid restriction. However, this care plan did not specifically address the resident’s dehydration diagnosis. Facility policy on comprehensive person-centered care plans required measurable objectives and timetables to meet residents’ needs, reflect current standards of practice, address underlying sources of problems, and be revised upon changes in condition or readmission from the hospital, but these requirements were not met for this resident’s dehydration.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Review of staff timecards showed that there was no DON present in the facility from 03/20/25 through 03/31/25, and on 04/01/25, the position remained vacant. The previous DON submitted a letter of resignation on 03/23/25, with immediate effect as of 03/24/25, leaving the facility without a DON for at least eight days. Interviews with the Assistant Director of Nursing (ADON), Human Resources, and the Administrator confirmed that the facility did not have a full-time or interim DON during this period. The ADON, who is an LVN, and a PRN RN, along with a Regional Clinical Support Specialist (also an LVN), attempted to provide coverage in the absence of a DON. The Administrator acknowledged that the facility was required to have a DON to manage the nursing department and that the absence of a DON led to issues with policies and regulations.
Failure to Follow Physician Orders for Wound Vac Settings
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not set the wound vac for a resident with a stage 4 pressure ulcer on the sacrum at the physician-ordered setting of 115mmHg. Instead, the wound vac was set at 125mmHg, which was not in accordance with the physician's orders. This discrepancy was observed during an interview and observation with the Director of Nursing (DON), who admitted to not checking the wound vac settings during wound care. The DON acknowledged that the wound vac was supposed to be set at 115mmHg and noted the risk of increased bleeding from suction due to the incorrect setting. The resident involved was a male with a history of sepsis, a pressure ulcer to the sacrum, and hemiplegia, with a severely impaired cognition as indicated by a BIMS score of 4. Despite the incorrect wound vac setting, the resident denied any discomfort or concerns with his wound care. Observations noted less necrotic tissue, granulation present, minimal drainage, some slough around the area, and no signs of infection. The facility's policy on wound treatment management required treatments to be provided in accordance with physician orders, but there was no specific policy for wound vac management. The physician confirmed that the nursing staff was expected to follow treatment orders as written and highlighted potential risks of not setting the wound vac correctly, such as increased drainage, discomfort, and pain.
Deficiency in Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with a history of urinary tract infection and neurogenic bladder, was observed with his catheter bag touching the floor, which is against the facility's policy. The resident was unable to recall when the staff last attended to him, indicating a lapse in regular monitoring and care. Interviews with the nursing staff, including an LVN and the DON, confirmed that catheter bags should be hung on the bed or wheelchair to prevent contamination and infection. The facility's policies on indwelling catheter use and infection prevention emphasize the importance of keeping catheter bags off the floor to reduce the risk of infection. Despite these policies, the staff failed to ensure the catheter bag was properly positioned, as observed during the survey. This oversight in catheter care could potentially expose residents to increased risks of disease and infection, highlighting a significant deficiency in the facility's adherence to its own care standards.
Environmental Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public across multiple areas. Observations revealed that the facility was not cleaned over a weekend due to insufficient housekeeping staff, resulting in unclean conditions such as dust, stains, and debris on floors in various halls. Additionally, a sharp container was found full, and there was confusion among staff about who was responsible for replacing it. Water leaks were observed from a condensation pipe in the Mechanical Room, causing water to overflow into the hallway and Janitor's Room. The Maintenance Supervisor acknowledged the issue but stated that he was not informed about the leak. Further observations highlighted inadequate safety measures during cleaning activities, with caution signs being disregarded or insufficiently placed, leading to potential hazards. In the Laundry Room, chemical dispensers were leaking solution onto walls and floors, and there was calcium buildup around the hand sink. The Oxygen Storage Room was found to be dusty and littered with debris. Interviews with staff revealed a lack of awareness and responsibility for maintaining cleanliness and safety in these areas.
Environmental Deficiencies and Inadequate Housekeeping Practices
Penalty
Summary
The facility was observed to have several environmental deficiencies that compromised the residents' right to a safe, clean, and comfortable environment. Observations revealed that the tile floors by the entrance and resident halls were dusty and stained, with paper particles scattered. A white tablet was found on the floor by the decentralized nurse's station in the 300 Hall. Additionally, a white sheet soaked with water was observed on the floor near the Janitor's Closet, with a caution sign placed directly in front. Water was leaking from a condensation pipe in the Mechanical Room, causing overflow into the hallway and Janitor Room, with the floor covered in dust and debris. The Maintenance Supervisor identified a rusted and cracked flapper as the cause of the leak, noting that the drain was checked only once a week. Housekeeping practices were also found to be inadequate. A housekeeper was observed mopping only 3/4 of the hallway and placing caution signs, as per her training. However, a Social Worker disregarded the caution sign and walked on the wet floor to reach resident rooms. Another housekeeper was seen mopping near the nurses' station with only one caution sign available, using her housekeeping cart to block the area due to a lack of additional signs. Furthermore, a dead cricket was found in the 200 Hall, and another white tablet was observed on the floor in the 400 Hall, confirmed by an LVN assigned to that area.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several deficiencies observed during the survey. For Resident #6, the facility did not ensure that a physician's order for Voltaren Gel included a specific dosage. This oversight was not reported to the physician or nurse practitioner, resulting in the medication being applied incorrectly by a medication aide. The Director of Nursing (DON) was unaware of the missing dosage, highlighting a lapse in communication and adherence to medication administration protocols. Resident #296 experienced a failure in communication when a medication aide did not notify the nurse after the resident refused to take Lactulose as prescribed. The resident expressed concerns about potential side effects, but the refusal was not documented or reported, leading to a missed dose. This incident underscores the importance of following procedures for reporting medication refusals to ensure proper care and documentation. For Resident #80, the facility did not administer Zinc Sulfate as ordered due to a lack of medication supply. The central supply clerk acknowledged the oversight in maintaining an adequate stock of over-the-counter medications, which resulted in the resident missing a scheduled dose. Additionally, the facility's staff failed to adhere to controlled substance protocols, with several instances of staff signing off on audit records before completing the required count with the on-coming nurse. These deficiencies indicate a need for improved medication management and adherence to established procedures.
Failure to Ensure Appropriate Use of Psychotropic Medications
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 five residents who were reviewed for unnecessary medications. The facility did not attempt gradual dose reductions (GDR) or document clinical contraindications for the continued use of these medications. Resident #6 was administered the antipsychotic medication Risperidone for agitation, despite having a diagnosis of non-Alzheimer's dementia and depression, with no symptoms of delirium, depression, or psychosis. The physician did not document GDR as clinically contraindicated, and the diagnosis for Risperidone was later changed to a mood disorder without appropriate justification. Similarly, Resident #18 was given Aripiprazole for depression, although it is not approved for use in older adults with dementia-related psychosis. The facility did not ensure that the medication was necessary for the resident's condition. Resident #32 received Olanzapine for dementia with psychosis, a diagnosis deemed inappropriate for the use of this antipsychotic medication. The diagnosis was later changed to delusional disorder, but the appropriateness of this diagnosis for Olanzapine use was still under question. Additionally, Residents #44 and #45 were prescribed psychotropic medications without a 14-day stop date, contrary to facility policy. The lack of proper documentation and adherence to medication protocols could lead to residents receiving unnecessary medications, posing potential risks to their health.
Medication Administration Errors and Unavailability
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 22% error rate during a medication administration observation. This was due to 12 errors out of 53 opportunities involving two residents. Med Aide E was responsible for these errors, which included failing to administer eight morning medications to one resident and not administering several medications to another resident according to physician's orders. One resident, who had a history of anxiety, depression, hypertension, and other conditions, experienced a significant issue when Med Aide E did not crush her medications as required. This led to the resident choking on a fish oil capsule, which was eventually expelled with assistance. The Med Aide did not attempt to administer the remaining medications or apply a prescribed Lidocaine patch. Additionally, the Med Aide failed to report the incident to the supervising nurse, which was against the facility's protocol. Another resident, recently admitted with a history of gastrointestinal bleed, atrial fibrillation, and other conditions, did not receive several critical medications due to their unavailability. The facility's process for obtaining medications after hours was not followed, leading to missed doses. The DON was unaware of the medication unavailability until after the fact, and the facility's policy for handling unavailable medications was not adhered to, resulting in a failure to notify the physician or obtain alternative treatment orders.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications, as observed in multiple medication carts across different halls. Specifically, liquid medications stored in medication carts on three halls had dried drippings on the sides of the bottles, indicating improper handling or storage. Additionally, medications were not stored according to their routes of administration, with oral medications being stored alongside nasal medications. One medication cart was found unlocked and unattended, posing a risk for drug diversion. Furthermore, a bottle of Betadine in the treatment cart had dried drippings, suggesting a lack of cleanliness and attention to detail in medication storage. The facility also failed to refrigerate opened bottles of Acidophilus Probiotic Dietary Supplement as required by the manufacturer's instructions. This was observed in all seven medication carts checked, with staff either unaware of the requirement or neglecting to follow it. These deficiencies in medication storage and handling could potentially affect residents by placing them at risk of not receiving their prescribed medications and increasing the likelihood of cross-contamination. Interviews with staff, including a Med Aide, LVN, and the DON, confirmed these lapses in adherence to the facility's medication storage policy, which mandates proper storage conditions and security for all medications.
Failure to Follow Manufacturer's Directions for Food Preparation
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, specifically in the preparation of instant mashed potatoes. During an observation and interview, it was revealed that a staff member responsible for preparing meals for 16 residents on pureed food diets did not follow the manufacturer's serving chart for instant mashed potatoes. Instead, the staff member estimated the amount of water and potato flakes needed to achieve the desired consistency for 20 servings, disregarding the manufacturer's instructions. In a subsequent interview and record review, the Dietary Manager confirmed that the recipe for mashed potatoes required following the manufacturer's directions for exact amounts. However, the Dietary Supervisor expressed confusion about the concern over not following these directions, as long as the consistency of the potatoes was deemed adequate. This deviation from the prescribed preparation method could potentially impact the nutritional value of the meal provided to the residents.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The kitchen was found to have multiple sanitation issues, including food preparation areas with food particles, white stains, and grease build-up on equipment and floors. Spice bottles and food coloring bottles were not clean, and trash cans were left uncovered. Additionally, food was not stored properly, with items in refrigerators and freezers not sealed or labeled, and perishable foods were not discarded when spoiled. The facility also failed to ensure that food was stored promptly after delivery, with boxes of food left on the floor. The dietary staff were reportedly not supervised adequately, leading to a lack of cleanliness and proper food storage practices. The dietary manager did not have written cleaning assignments, and staff were observed using cell phones during meal preparation instead of focusing on their tasks. The facility had been without a dietary manager for two months, contributing to the oversight issues. Furthermore, the facility did not follow proper procedures for washing dishes in the three-compartment sink, as the chemical levels for sanitization were not checked correctly. The dietary manager was unaware of the correct procedures and failed to ensure that the sanitizing solution was at the appropriate concentration. These deficiencies in food safety and sanitation practices could potentially place residents at risk of foodborne illnesses.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility's kitchen was found to have multiple sanitation and storage deficiencies during an initial tour. Observations included food particles and dried stains on various surfaces, such as shelves, tables, and floors. The deep fryer contained crumbs and chicken pieces, while the tile floor had black stains and food debris. Spice bottles and other containers were greasy and improperly sealed, and a large trash can was uncovered. Additionally, the ice scoop was stored improperly, and food items were left on the floor due to a recent delivery. The Dietary Manager admitted to a lack of written cleaning assignments, relying on staff to clean their own areas. In the dry storage area, containers were found with grease buildup and food particles, and some onions were moldy and mushy. Refrigerators contained undated and improperly sealed food items, including cornflakes, whipped cream, broccoli, and various meats. The bottom shelves of the refrigerators had food particles and stains, and several cardboard boxes were not sealed. The facility's pureed food preparation process was also scrutinized, revealing that staff did not follow manufacturer directions for consistency, particularly with mashed potatoes. The dishwashing area had a broken drain cover with black stains, and food temperatures were checked, revealing some items below the required temperature. The Dietary Manager confirmed that the deep fryer should be cleaned after each use, and there was a misunderstanding regarding the importance of following manufacturer directions for pureed foods. The facility's failure to maintain cleanliness and proper food storage practices led to these deficiencies, as observed by the surveyors.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, specifically the Medical Director or their representative, for 5 out of 9 Quality Assurance and Performance Improvement (QAPI) meetings reviewed. Interviews and record reviews revealed that the Medical Director attended only one QAPI meeting in 2023 and none in 2024, despite the facility's policy requiring their presence. The Director of Nursing (DON) confirmed that the Medical Director was expected to attend these meetings, but the signature sheets for the meetings on 07/13/23, 08/23/23, 04/24/24, 05/22/24, and 07/24/24 showed their absence. The facility's policy, dated 07/2022, mandates that the QAA committee be interdisciplinary and include the Director of Nursing Services, Medical Director, at least three other staff members, including the Administrator and Infection Preventionist. The committee is required to meet at least quarterly to coordinate and evaluate activities under the QAPI program. The absence of the Medical Director or their designee from these meetings could lead to unidentified quality deficiencies, lack of appropriate action plans, and insufficient guidance, as noted in the report.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations across different areas. In Hall 300, a dirty linen hamper was observed to be full and not properly sealed, which could lead to cross-contamination. On the treatment cart, an opened bag of non-sterile gauze sponges was found stored improperly without being sealed in a plastic bag, as confirmed by the Treatment Nurse. This practice increases the risk of cross-contamination. Additionally, in the storage room on Hall 100, six mattresses were stored directly on the floor, which is against the facility's policy to prevent contamination. Further observations revealed that in Hall 400, a backpack was improperly stored in the clean linen closet, contrary to the facility's training for staff to avoid storing personal belongings in such areas. On Hall 200, the medication cart contained an opened package of non-woven sponges that were not stored in a sealed plastic bag, as noted by the Director of Nursing. These findings indicate a lack of adherence to the facility's infection control policies, which require proper storage and handling of resident-care equipment and environmental surfaces to prevent the spread of infections.
Resident Privacy Violation Due to Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident by not covering the resident's indwelling urinary catheter bag. The resident, who had a moderate cognitive impairment and a diagnosis of neuromuscular dysfunction of the bladder, was observed with an uncovered foley bag hanging by the side of his bed, facing the door. This observation was made during a survey, and it was noted that the facility's policy required catheter drainage bags to be covered at all times to maintain privacy. Interviews with staff, including a registered nurse (RN) and the Director of Nursing (DON), confirmed that the exposure of the foley bag violated the resident's privacy and could lead to feelings of shame. Both the RN and DON acknowledged that all staff, including CNAs, LVNs, and RNs, were responsible for ensuring that privacy bags were used to cover catheter bags. The facility's policy on catheter care, dated July 2022, explicitly stated that privacy bags should be available and used to cover catheter drainage bags at all times.
Failure to Accommodate Resident's Monitoring Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by obstructing the view of an electronic monitoring camera placed in the resident's room by the family. The resident, who had severe cognitive impairment and required assistance with daily activities, had a camera installed by the family to monitor the care being provided. The family member reported that facility staff regularly blocked the camera's view during care, despite having discussed this issue with both the Director of Nurses (DON) and the Administrator. The staff were instructed to block the camera during incontinent care to protect the resident's privacy, as per the facility's practice. The facility's policy on electronic monitoring, which aligns with state regulations, indicates that intentionally obstructing a monitoring device is a misdemeanor. Despite this, the facility continued to block the camera, citing the preservation of the resident's dignity as the reason. The family member, who was the resident's responsible party and Power of Attorney, had signed a document acknowledging the facility's policy on electronic monitoring. However, the family member's request to keep the camera unobstructed was not honored, as the facility prioritized privacy concerns over the family's monitoring preferences.
Failure to Notify Physician of Medication Unavailability and Dosage Errors
Penalty
Summary
The facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for two residents. Resident #295, who was admitted with a history of gastrointestinal bleed, atrial fibrillation, pneumonia, hypertension, shortness of breath, and asthma, did not receive several prescribed medications, including Amiodarone HCL, Famotidine, Budesonide Inhalation Solution, and Cholestyramine Oral Packet, during the morning medication pass. The medications were not available in the automated medication dispensing system, and the facility did not notify the physician or nurse practitioner about the unavailability of these medications. Additionally, Resident #6, who had a diagnosis of Diabetes Mellitus, Pulmonary embolism, Hypertension, and Dementia, had a physician's order for Voltaren Gel that did not specify a dosage. The medication was applied without a proper dosage, and the physician was not notified to obtain the correct dosage. Furthermore, the administration of Fluticasone Propionate nasal spray was not performed according to the manufacturer's instructions, as the resident was not asked to blow her nose prior to use, and one nostril was not closed during administration. The facility's policy on Notification of Changes and Unavailable Medications was not followed, as the staff failed to notify the physician of the inability to obtain medications and did not obtain alternative treatment orders. The lack of communication and adherence to procedures resulted in the residents not receiving their prescribed medications as ordered, which could potentially delay medical treatment.
Privacy Concerns with Camera Use in Resident Rooms
Penalty
Summary
The deficiency involves the privacy and confidentiality of residents' personal and medical records, specifically concerning the use of cameras in resident rooms. A resident and their family expressed concerns about privacy, leading to actions such as covering the camera with a pillow for privacy reasons. The Director of Nursing (DON) was involved in instructing staff to block the cameras, citing dignity concerns. There was also confusion about whether the television and lights left on at night were for the resident in question or another resident. The report mentions that the camera was moved from the head of the bed to the side, but it was then covered, preventing proper monitoring. Additionally, there was a mention of a potential fire concern due to the camera's placement near a light fixture. The family expressed uncertainty about the care provided, highlighting a balance issue between resident privacy and family rights to monitor care. The facility's policy on cameras was referenced, but it appears there was a lack of clear guidance or adherence to regulations regarding camera use and privacy.
Failure to Conduct PASARR Screening for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was diagnosed with schizophrenia. The resident, who was admitted with a principal diagnosis related to a feeding tube, had a history of dementia, delusional disorders, and major depressive disorder. Despite the new diagnosis of schizophrenia being added to her records, the facility did not conduct a new Level 1 PASARR screening, which is required to determine eligibility for specialized services. Interviews with facility staff, including the MDS Nurse and the Director of Nursing (DON), revealed that the new diagnosis should have triggered a rescreening process. The MDS Nurse acknowledged the oversight and emphasized the importance of rescreening to ensure residents receive necessary services. The facility's policy required PASARR evaluations for residents with serious mental illnesses, such as schizophrenia, but did not specify procedures for new diagnoses. This oversight could potentially risk residents not receiving the specialized services they are entitled to.
Failure to Maintain Proper Wound Care for Resident with LVAD
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an external cardiac pacemaker, specifically an LVAD, by not ensuring that the dressing on the LVAD driveline exit site was dated when changed and was not draining onto the resident's gown and skin. This oversight was observed during an interview and inspection, where it was noted that the dressing was not dated, and there was visible brownish-red drainage on the resident's gown. The LVN acknowledged that the dressing should have been dated and changed as needed to prevent infection. The resident, who had a history of heart failure, cardiomyopathy, kidney failure, and other significant health issues, was dependent on staff for various activities of daily living. The resident's care plan indicated a risk for complications due to the LVAD. Despite having physician's orders for regular dressing changes and antibiotic treatment for an LVAD infection, the facility did not adhere to these orders, as evidenced by the undated and soiled dressing. Interviews with the LVN and the DON revealed that the facility's protocol required wound dressings to be dated to track when care was provided and to prevent infections. The DON confirmed that the condition of the dressing should have been identified during routine nursing rounds and addressed promptly. The failure to maintain proper wound care practices increased the resident's risk of infection, as indicated by the positive test results for infection and the subsequent antibiotic treatment.
Deficiency in Respiratory Care and Oxygen Storage
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #192, who required continuous oxygen therapy. The resident, who had diagnoses including dementia, pneumonia, and acute respiratory failure with hypoxia, was observed without her nasal cannula, which was supposed to be worn continuously as per physician's orders. The nasal cannula was found uncovered on a small chest beside her bed, posing an infection risk. The resident reported that staff had forgotten to put the cannula back on after her bath. Interviews with staff, including an LVN and the DON, confirmed that the nasal cannula should have been on the resident at all times and covered when not in use to prevent infection. Additionally, the facility failed to properly manage oxygen storage. Four metal oxygen cylinders were found stored in a scale room without an oxygen sign posted on the door, contrary to the facility's policy that required oxygen cylinders to be stored only in the designated oxygen storage room. The central supply clerk and the DON acknowledged the improper storage and the lack of signage, which could potentially impact the availability of oxygen support for residents requiring oxygen therapy.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for one resident. Specifically, the physician did not respond timely to the Pharmacist Consultant's recommendation to evaluate the continued need for iron sulfate beyond eight weeks of therapy, as per CMS guidelines. The medication was eventually discontinued, but not until over a month after the recommendation was made. The deficiency involved a resident with multiple diagnoses, including anxiety, depression, hyperlipidemia, hypertension, hypothyroidism, vitamin D deficiency, and GERD. The resident was receiving ferrous sulfate as a supplement, and the Pharmacist Consultant recommended evaluating its necessity. However, there was no system in place to ensure that such recommendations were promptly acted upon by the physician, leading to a delay in addressing the potential for unnecessary medication.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center for a resident requiring dialysis services. The resident, a male with end-stage renal failure on hemodialysis, had a care plan that did not include maintaining communication with the dialysis center. This lack of communication was evident in the incomplete dialysis communication forms, which were meant to document vital signs, weights, dialysis times, and other critical information. Interviews with staff revealed that the charge nurse responsible for the resident was unaware of the incomplete forms due to her shift timing. The afternoon charge nurse, who was supposed to ensure the forms were completed, did not notice any discrepancies. The Director of Nursing (DON) also admitted to not noticing the discrepancies until the forms were submitted to the surveyor. The dialysis center staff acknowledged the difficulty in keeping up with the forms and stated that they had not received any follow-up calls from the facility regarding the lack of documentation. The facility's hemodialysis policy required communication with the dialysis facility through forms or telephone, including details like physician orders, vital signs, and nutritional management. However, the policy was not followed, leading to incomplete documentation and a potential risk of missing changes in the resident's condition. The DON noted that the current staff was relatively new, and there was uncertainty about the training provided by the previous administration.
Deficiencies in Documentation and Incident Reporting
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and incident reporting. For Resident #2, the facility did not document an allegation of being called 'stupid' and handled roughly by a CNA during ADLs in the progress notes, nor was an incident report completed. This oversight was confirmed during an interview with the Administrator, who acknowledged the lack of documentation and incident reporting. In another case, the facility did not accurately document a resident-to-resident altercation between Residents #1 and #4. The progress notes for Resident #1 mentioned the altercation, but there was no corresponding assessment or incident report for Resident #4. Interviews with staff, including the LVN and ADON, revealed that although the incident was reported verbally, it was not documented in the facility's electronic records, and no incident report was filed. The facility's failure to document these incidents and complete incident reports as per policy could place residents at risk of not receiving needed services. The lack of documentation and incident reporting was acknowledged by the DON, who stated that the absence of incident reports could lead to inaccurate details of incidents, lack of monitoring, and failure to notify relevant parties. The facility's policy on incidents and accidents requires incident reports for resident-to-resident altercations, which were not completed in these cases.
Facility Fails to Repair Broken Window, Compromising Resident Safety
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public, as evidenced by a broken window in one of the resident rooms. The broken window was covered with cardboard and plastic, which allowed air and dust to enter the room, potentially affecting the respiratory health of the residents. This issue was first reported by the Maintenance Director in January 2024, but the window remained unfixed by June 2024, despite multiple follow-ups with the facility's President and the builder responsible for the window replacement. Resident #7, who was on oxygen therapy, reported experiencing difficulty breathing and increased sneezing due to the dust and air entering through the broken window. The resident's oxygen saturation levels were recorded between 92% and 97% during the period from June 2 to June 25, 2024. The resident's roommate, also on oxygen, was asleep during the observation. The Director of Nursing (DON) acknowledged the broken window and the associated risks, including dust, wind, and insects entering the room, but was unaware of the window's history as she had started working at the facility after the incident occurred. The Maintenance Director explained that the window was broken by a resident and that the builder was contacted to replace it under warranty. However, the replacement was delayed due to the need for a special order. The Administrator confirmed that the broken window had been reported months ago and that a work order was placed, but the facility was unaware of the need to make specific arrangements for the order, which prolonged the repair process. The facility's policy on providing a safe and homelike environment was not dated, but it emphasized the importance of ensuring a safe, clean, and comfortable environment for residents.
Failure to Conduct Timely Background Check on Administrator
Penalty
Summary
The facility failed to implement its written policies that prohibit and prevent abuse by not conducting a criminal background check on the Administrator before she began her duties. The Administrator started working on December 4, 2023, but her criminal background check was not completed until December 14, 2023. This oversight was discovered during an audit by HR in December 2023, who then conducted the background check to ensure it was on record. However, there was no documentation or proof from corporate that a background check had been completed prior to the Administrator's start date. Interviews with HR personnel revealed inconsistencies in the process of conducting background checks. The Retail HR claimed to have run the Administrator's background check on December 1, 2023, but corporate did not have a record of this check. The facility's policy on abuse, neglect, and exploitation requires that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, with documentation maintained as proof. The failure to adhere to this policy could place residents at risk of potential abuse.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged abuse incident involving two residents within the required timeframe. The incident occurred when one resident reportedly hit another with a cane after a minor altercation involving a wheelchair. The facility's staff, including the LVN and ADON, were aware of the incident and took immediate steps to separate the residents and ensure safety. However, the incident was not reported to the appropriate authorities, such as the State Survey Agency and adult protective services, as required by state law. The deficiency involved two residents, one of whom had a severely impaired cognitive status as indicated by a BIMS score of 1. The altercation was documented in progress notes, but there was no evidence of a skin assessment or further documentation regarding the incident for the resident with cognitive impairment. The facility's policy required immediate reporting of such incidents, but the DON and Administrator did not ensure that the incident was reported to the necessary agencies. Interviews with staff revealed that the facility's corporate office decided the incident was not reportable due to insufficient evidence of physical harm. Despite this, the facility's policy mandates reporting all alleged violations, regardless of the perceived severity. The lack of timely reporting could place residents at risk of continued abuse, as the facility did not adhere to its own policies and state regulations.
Failure to Document Wound Care Properly
Penalty
Summary
The facility failed to provide necessary treatment and services based on the comprehensive assessment and professional standards of practice for a resident diagnosed with lymphedema, chronic venous hypertension, leg wound, and elephantiasis. The resident's care plan included wound care for venous ulcers, which required regular dressing changes and documentation. However, observations revealed that the dressings on the resident's left foot and leg were not dated or initialed, and the edges were peeling off, exposing the gauze and wound. Interviews with the resident and staff, including the Director of Nursing (DON) and Registered Nurse (RN) C, indicated discrepancies in the frequency of wound care provided. The resident stated that dressings were changed once a week, while the administration reported wound care was ordered three times a week. The DON and RN C confirmed that dressings should be dated and initialed as part of standard procedures to prevent infection and ensure accountability. RN C admitted to providing wound care but did not date or initial the dressings, and the Wound Care Nurse emphasized the importance of changing dressings with peeling edges and yellowish substances. The facility's wound treatment management policy aimed to promote wound healing through evidence-based treatments and required dressing changes to be documented. However, the failure to date and initial the dressings, as well as the lack of communication among staff regarding the condition of the dressings, contributed to the deficiency. This oversight posed a risk of infection and deterioration of the resident's condition, as noted by the staff during interviews.
Incomplete Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, dated April 24, 2023, was incomplete, notably lacking a staffing plan. This oversight was identified during a review of the facility's records and interviews with staff. The Director of Nursing (DON) acknowledged receiving an email from the Administrator about the overdue assessment but had not completed her section on staffing. The Administrator admitted to being out of compliance with the facility's policy, which mandates an annual assessment, and attributed the delay to issues with a previous interim DON. The Administrator further explained that the facility assessment should be completed annually and recognized the lack of a documented staffing ratio plan as a risk. Despite sending an email to department heads with the assessment template, the Administrator did not recall notifying corporate about the interim DON's inadequacies, which contributed to the delay. The facility's policy, dated July 2022, requires the assessment to be reviewed and updated annually or when significant changes occur, considering specific needs for each shift and resident unit. However, this policy was not adhered to, resulting in the deficiency.
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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