Avir At Winnsboro
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnsboro, Texas.
- Location
- 910 S Beech St, Winnsboro, Texas 75494
- CMS Provider Number
- 675812
- Inspections on file
- 30
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Avir At Winnsboro during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
Surveyors found that pulled pork was thawed at room temperature, frozen foods were not labeled or dated, and cooking trays were stored improperly. Staff interviews confirmed these actions did not follow required food safety standards or facility policy.
Residents and staff reported that meals were often bland, cold, or unappetizing, with several residents relying on snacks due to dissatisfaction with facility food. A test tray evaluation confirmed that food lacked flavor and proper temperature, and the dietary manager identified the absence of plate warmers as a contributing factor. These issues were corroborated by multiple resident complaints and observations by the survey team.
A resident with a JP drain did not have this device or its required care interventions included in their care plan, despite physician orders and ongoing need for monitoring and site care. The omission was not identified by staff until surveyors intervened, and the facility's policy requiring comprehensive, person-centered, and current care plans was not followed.
A resident with multiple medical conditions and impaired cognition, who required oxygen therapy, was found to have an oxygen concentrator without a filter on several occasions, despite documentation indicating weekly maintenance had been completed. Staff interviews confirmed the filter should have been present and clean, in accordance with physician orders and facility policy.
A resident with PTSD and a history of trauma did not have his specific triggers, such as loud noises and water, included in his care plan. Direct care staff were unaware of these triggers, and the facility lacked a trauma-informed care policy, resulting in a failure to provide care in accordance with professional standards.
A resident with multiple diagnoses, including Alzheimer's and depression, continued to receive a higher dose of mirtazapine than ordered after a physician signed off on a pharmacy recommendation to reduce the dose. The medication order was not updated due to a breakdown in communication and follow-up among nursing staff, resulting in the resident receiving unnecessary medication.
The facility had a medication error rate of 6.9% after two residents did not receive their medications as ordered: one received an insufficient dose of Omeprazole, and another received only one spray of fluticasone instead of two. Nursing staff did not follow physician orders during medication administration, contrary to facility policy.
A resident with severe cognitive impairment was found to have hibiclens antiseptic skin cleanser stored on a bathroom shelf in her room on multiple occasions. Facility staff, including an LVN, DON, and Administrator, confirmed that the cleanser should not have been accessible and should have been stored in a locked medication room or cart, in accordance with facility policy. The failure to secure the hibiclens was acknowledged as a breach of protocol.
The facility did not accurately document its facility-wide assessment, omitting a resident who required dialysis from its records. This resident, who had chronic kidney disease and other significant health conditions, was receiving dialysis multiple times per week. The administrator acknowledged the oversight, and the DON confirmed there was no policy in place for facility assessments.
A resident with dementia and high elopement risk left the facility unsupervised, walking 0.5 miles and crossing a busy road. Despite being classified as high risk, the facility failed to implement effective measures to prevent the resident from leaving. The ADON witnessed the resident climbing the fence but did not prevent the elopement. The resident was eventually found by a hospice nurse and family members, highlighting a lack of supervision and communication among staff.
Two residents in a facility experienced abuse due to inadequate monitoring and intervention. One resident was choked and struck by another, while another resident was slapped due to agitation over noise. The facility failed to prevent these incidents, despite one resident having a history of aggressive behavior.
A CNA/Van Driver misappropriated a resident's debit/credit card, conducting 59 unauthorized transactions. The resident, with dementia and moderate cognitive impairment, was unable to protect their financial resources. The facility's social worker and fiduciary noticed unusual transactions, leading to a police investigation that confirmed the CNA/Van Driver's actions. The CNA/Van Driver was terminated following the confirmation of misappropriation.
The facility failed to provide a safe, clean, and comfortable environment for a resident and the dining room. A resident's bathroom had a strong odor of urine and broken tiles, while the dining room used plastic, folding tables that were not conducive to comfortable dining. Despite staff awareness, no corrective actions were taken.
The facility failed to address grievances from residents about unmade beds and cold food, as documented in Resident Council meetings. Observations confirmed these issues, with unmade beds and cold meal trays reported by residents. Staff interviews revealed inadequate grievance management, with the DON expecting departments to resolve issues, but the process was not effectively implemented.
The facility failed to deliver resident mail on weekends, impacting their right to communication and potentially affecting their psychosocial well-being. Residents reported not receiving mail on weekends, and interviews revealed confusion about mail delivery responsibilities. The local Postmaster indicated mail was stopped on weekends, and there was no facility policy regarding mail delivery.
A facility failed to update a resident's care plan to reflect a change in code status from full code to DNR, despite having a signed DNR order. The resident, with severe cognitive impairment, was at risk of receiving unwanted CPR due to this oversight. Interviews indicated that nursing leadership was responsible for timely updates, which were not made according to facility policy.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as secure unit placement, smoking habits, prophylactic antibiotic use, and PTSD triggers. Observations and interviews revealed a lack of documentation and oversight, posing risks to resident safety and care.
The facility failed to ensure a fall mat was in place for a resident as required by her care plan, and did not conduct monthly smoking assessments for two residents, contrary to facility policy. The absence of a fall mat was acknowledged by an RN and the DON, while the lack of smoking assessments was due to a misunderstanding of the policy by the social worker, who believed assessments were annual rather than monthly.
A long-term care facility failed to administer medications on time for four residents, including those with severe cognitive impairment and chronic conditions. Medications were given significantly later than scheduled due to a staff member arriving late for an unscheduled shift. The delay in administration was acknowledged by the DON and other staff, highlighting the importance of timely medication delivery.
A resident with dementia and severely impaired cognition continued to receive the antipsychotic medication Seroquel despite a pharmacy recommendation and physician agreement to discontinue it. The facility failed to implement the physician's order, resulting in the resident receiving 13 additional doses. The DON and Regional Director acknowledged the oversight and emphasized the responsibility of nurse management in following pharmacy recommendations.
A long-term care facility reported a 38% medication error rate, with four residents receiving medications late due to a medication aide's late arrival for a shift. Residents with cognitive impairments and various diagnoses, including seizures and high blood pressure, were affected. The facility's DON and RDO acknowledged the potential impact on medication effectiveness and resident health.
The facility failed to provide food at a palatable and safe temperature for seven residents. Residents reported receiving cold meal trays, and observations confirmed that food was not served on warmed plates. Interviews with staff highlighted the lack of a policy on food palatability and the shared responsibility between nursing and dietary departments to ensure meals are served at the correct temperature.
A facility failed to update a resident's comprehensive care plan to reflect a change in code status from full code to DNR, despite having a physician order and family consent for DNR. The resident, with severe cognitive impairment and multiple diagnoses, was at risk due to this oversight. Interviews with the DON and Regional Clinical Consultant confirmed the expectation for timely updates to care plans.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of a resident's catheter bag, inadequate incontinent care by a CNA, and poor laundry practices. A resident's catheter bag was repeatedly observed on the floor, and another resident received improper peri care without proper hand hygiene. Laundry staff handled soiled linen without PPE and transported clean laundry uncovered, risking cross-contamination.
The facility failed to notify the representatives of two residents immediately following significant changes in their conditions due to falls. Despite the facility's policy, the responsible nurse forgot to inform the families, and the Director of Nursing acknowledged the oversight.
Two residents experienced a lack of dignity in their care at an LTC facility. One resident's catheter bag was left uncovered, visible from the hallway, against care plan instructions. Another resident was fed by a CNA standing over them, contrary to the practice of sitting at eye level. Staff interviews confirmed these actions were not in line with dignity-preserving practices.
A resident with dementia and a history of falls had her call light repeatedly found out of reach, despite care plan instructions. Staff interviews confirmed the responsibility to ensure call lights are accessible, but the facility lacked a specific policy on this matter.
A medication aide in an LTC facility left the EMR of two residents open and visible on the medication cart during medication administration, potentially exposing sensitive information. The residents involved had conditions such as heart failure, keratoconjunctivitis, and major depressive disorder. Staff interviews confirmed the expectation to protect resident privacy.
The facility failed to report injuries of unknown origin for two residents, as required by their abuse prevention policy. One resident, with Alzheimer's and other conditions, was found with bruising on her perineum after a fall, but the injury was not reported to HHSC. Another resident, with multiple diagnoses, was found with bruising on his buttocks and chest, which was also not reported. The facility's failure to adhere to reporting requirements represents a significant deficiency.
The facility failed to report injuries of unknown origin for two residents to the appropriate authorities within the required timeframes. One resident, a female with Alzheimer's, was found with bruising on her perineum after a fall, which staff attributed to the fall and did not report. Another resident, a male with severe cognitive impairment, was found with bruising on his buttocks and chest, which was also not reported. This deficiency could place residents at risk for further neglect.
A resident's MDS assessment inaccurately recorded a weight loss despite a documented weight gain, due to a human error by the MDS Coordinator. The resident, with multiple medical conditions, was noted to have gained 9.3% of his body weight, but the MDS indicated a loss. The DON and Regional Director acknowledged the importance of accurate assessments, though the facility lacked a specific policy on MDS accuracy.
A resident with a diabetic ulcer did not receive proper monitoring and care as required by professional standards. Despite having a care plan for regular wound assessments, the facility failed to document necessary measurements, relying instead on podiatrist visits. Interviews with staff revealed a lack of adherence to the facility's skin integrity monitoring policy, which required regular documentation of skin conditions.
A facility failed to provide trauma-informed care for a resident with PTSD, as a trauma assessment was not completed upon admission, and staff were unaware of the resident's triggers. The resident's care plan did not reflect his PTSD diagnosis, leading to potential risks of re-traumatization due to loud noises and water.
The facility failed to secure drugs properly, with a medication cart left unlocked and a lock box for controlled drugs not affixed in the refrigerator. A medication aide admitted to leaving the cart unlocked, and a liquid Lorazepam bottle was found in an unaffixed lock box. The DON and RDO were unaware of these issues, which could lead to drug diversion.
A resident lost his dentures, and the facility failed to provide necessary dental services due to a lack of policy and communication. Despite a physician's order for dental consults, no referral was made, and the resident's family expressed concerns. The Social Worker and DON were unaware of any policy regarding lost dentures, leading to inaction.
The facility's kitchen was found to have unsanitary conditions, including grease buildup on sheet pans, carbon buildup on cast iron skillets, and dust on a juice machine. Staff interviews revealed that these items were not included in the cleaning schedule, and the Dietary Manager acknowledged the potential risk of illness. The facility's policies emphasize the need for clean food-contact surfaces to prevent food-borne illnesses.
The facility failed to coordinate hospice care and maintain documentation for two residents receiving hospice services. One resident's hospice binder was missing, hindering communication and care management, while another resident's hospice plan of care was outdated, risking incorrect medication administration. Interviews revealed that hospice staff were behind in updating care plans, and there was no facility policy on hospice services, leading to inadequate coordination and communication.
A facility failed to ensure proper documentation for the use of Zithromax in a resident with metabolic encephalopathy, dementia, and diabetes. Despite the absence of documented symptoms like fever or cough, the resident was administered the antibiotic. Interviews with staff revealed a lack of documentation supporting the antibiotic's use, contrary to the facility's antibiotic stewardship policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Improper Food Thawing, Labeling, and Storage in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Three packages of pulled pork were found thawing at room temperature on a table, still solid and not submerged in water or under refrigeration as required. Several bags of frozen cinnamon rolls and sweet potato fries were stored in freezer bags without labels or dates, and peas and an unidentified breaded meat were also found in sealed bags with no labeling or dating, with the peas showing frost buildup. Additionally, cooking trays and muffin trays were improperly stored in an office between open cardboard boxes, rather than in a designated storage area. Interviews with the dietician and dietary manager confirmed that these practices did not align with professional standards or the facility's own policies, which require proper thawing methods, labeling, and storage of food and equipment. The administrator acknowledged that it was the responsibility of all relevant staff to ensure compliance with safe food handling procedures, including proper thawing, labeling, and storage of food and cookware. The facility's documented policies also specify that food must be thawed in a refrigerator or under running cold water, and all stored food must be labeled and dated.
Failure to Provide Palatable and Properly Tempered Food to Residents
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the quality and temperature of the food, describing it as bland, overcooked, cold, or having unusual flavors. One resident stated he avoided eating facility meals and relied on snacks in his room, while others echoed concerns about the food being consistently cold and unappetizing. Anonymous complaints during a resident council meeting also highlighted issues with food temperature and meal timing. During a test tray evaluation, both the dietary manager and state survey team found the sampled meal to be lacking in flavor and temperature, with specific items such as lemon butter chicken and vegetables described as bland or overpowered by certain flavors. The dietary manager noted that the lack of plate warmers contributed to the food cooling quickly after plating. The DON and administrator acknowledged that residents who disliked the food might be at risk for malnutrition and weight loss, and it was noted that resident satisfaction declined after a change in food providers. The facility's policy required regular test tray evaluations, but the issues persisted as observed and reported.
Failure to Care Plan JP Drain for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had a Jackson Pratt (JP) drain following surgery. Despite physician orders specifying that the JP drain should be emptied and drainage documented each shift, the site cleansed and dressed every shift, and the site monitored for signs of infection, these interventions were not included in the resident's care plan. The resident's admission MDS assessment did not mention the JP drain, and the care plan, as of its last revision prior to surveyor intervention, did not address the presence or care of the JP drain. Observations confirmed the resident had a JP drain in place, and interviews with staff revealed that the omission was not recognized until brought to their attention by surveyors. The MDS coordinator and other members of the interdisciplinary team (IDT) were responsible for developing and updating care plans, but the JP drain was not care planned despite being present since admission. The Director of Nursing (DON) and Administrator both acknowledged that the care plan should reflect all aspects of a resident's care, and that the omission could impact the resident's care. Facility policy required that care plans be comprehensive, person-centered, and kept current, but this was not followed in the case of the resident with the JP drain.
Failure to Maintain Oxygen Concentrator Filter for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident who required oxygen therapy did not have a filter in her oxygen concentrator, as observed on multiple occasions over several days. The resident, an elderly female with diagnoses including heart failure, a history of COVID, altered mental status, anxiety, and high blood pressure, had severely impaired cognition and was dependent on staff for activities of daily living. Her care plan and physician orders specified that oxygen tubing, bubble humidification, and filters were to be changed and cleaned weekly by the night shift nurse. Documentation indicated that the required maintenance was signed off as completed, but direct observation revealed the filter was missing from the concentrator. Interviews with staff, including an LVN, the DON, and the Administrator, confirmed that the filter should have been present and clean, and that its absence was contrary to facility policy and physician orders. The facility's policy required filters to be washed every seven days, and only trained licensed staff were to administer and maintain respiratory therapy equipment. The failure to ensure the filter was in place was acknowledged by staff and administration during interviews, and it was noted that the responsible night shift nurse could not be reached for clarification.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. The resident's care plan did not include specific triggers related to his PTSD, despite documentation in his trauma assessment and direct communication from the resident about his triggers, which included loud noises, war pictures, and water. Staff interviews revealed that direct care staff, including a CNA and an LVN, were either unaware of the resident's PTSD diagnosis or did not know his specific triggers. The care plan only generally referenced the risk of the resident being startled, without specifying the known triggers. Further, the social worker and MDS coordinator acknowledged that the resident's triggers were not included in the care plan, and the social worker confirmed that this information should have been documented to inform staff. The DON and administrator both stated that the care plan should reflect the trauma assessment and include specific triggers so staff could provide appropriate care. At the time of the survey, the facility did not have a policy on trauma-informed care, and there was no evidence that staff had been formally in-serviced on the resident's specific triggers.
Failure to Implement Physician-Ordered Antidepressant Dose Reduction
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, diabetes, heart disease, depression, and anxiety continued to receive an unnecessary dose of Remeron (mirtazapine), an antidepressant medication, despite a signed physician order to decrease the dose. The pharmacy had recommended, and the medical director agreed, to reduce the resident's Remeron from 22.5mg to 15mg nightly. However, the medication administration record showed that the resident continued to receive the higher dose for an extended period after the order was signed. The failure was attributed to a breakdown in the facility's process for implementing pharmacy recommendations and physician orders. The DON stated that the charge nurse is responsible for updating orders and providing documentation for follow-up, but in this case, the signed order to decrease the medication was not properly communicated or acted upon. As a result, the resident continued to receive a higher dose of medication than was necessary, contrary to facility policy and regulatory requirements.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.9% based on 2 errors out of 29 observed opportunities. One error involved a male resident with coronary artery disease, dementia, GERD, and hypertension, who was ordered to receive Omeprazole 20 mg, two tablets by mouth twice daily. On the observed date, the nurse administered only one 20 mg tablet instead of the prescribed two, resulting in an underdose. The resident's care plan required medications to be administered as ordered and for staff to monitor and document side effects and effectiveness. A second error involved a female resident with heart failure, dementia, GERD, and hypertension, who was ordered to receive Flonase Allergy Relief (fluticasone) nasal spray, two sprays in each nostril twice daily. During medication administration, the nurse administered only one spray instead of the prescribed two. The nurse later acknowledged the mistake, stating she thought she had given two sprays but realized she had not. The facility's policy required medications to be administered and documented as ordered by the physician and in accordance with state regulations.
Improper Storage of Antiseptic Cleanser in Resident Room
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition, as indicated by a BIMS score of 3 and a care plan noting an ADL self-care deficit, was found to have hibiclens antiseptic skin cleanser stored on a bathroom shelf in her room. Multiple observations on consecutive days confirmed the presence of the hibiclens in the resident's bathroom. The resident's medical history included heart failure, altered mental status, anxiety, and high blood pressure, and she required supervision and assistance with activities of daily living, including bathroom use and showers. Interviews with facility staff, including an LVN, the DON, and the Administrator, confirmed that the hibiclens antiseptic cleanser should not have been accessible in the resident's room and should have been stored in a locked medication room or cart. The facility's policy required that medications be stored securely and only accessible to authorized personnel. Staff acknowledged that the presence of the hibiclens in the resident's bathroom was a failure to follow policy and placed the resident and others at risk, as the cleanser is not intended for resident possession.
Failure to Accurately Document Facility Assessment for Dialysis Care
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 routine operations and emergencies. Specifically, the assessment did not accurately reflect the presence of a resident receiving dialysis, as it listed zero residents requiring this special treatment. This omission was identified during a review of the facility assessment, which had not been updated to include the dialysis patient, despite the resident's ongoing need for dialysis services. A male resident with chronic kidney disease, malignant neoplasm of the kidney, diabetes, and high blood pressure was admitted to the facility and required dialysis three times a week. Documentation confirmed the resident's cognitive intactness and dependence on staff for multiple activities of daily living. The administrator acknowledged the oversight during an interview, stating that the dialysis patient should have been included in the facility assessment. Additionally, the Director of Nursing confirmed that the facility did not have a policy for conducting facility assessments.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for a resident who was at high risk for elopement. The resident, who had a history of dementia with behavioral disturbances, anxiety, depression, and hypertension, was able to leave the facility unsupervised. This resident had a severely impaired cognition with a BIMS score of 4 and was receiving hospice care. Despite being classified as high risk for wandering, the facility did not implement effective measures to prevent the resident from leaving the premises. On the day of the incident, the resident expressed a desire to go home and exhibited agitated behavior. The resident was taken outside for a scheduled break but refused to return inside. The Assistant Director of Nursing (ADON) witnessed the resident climbing the fence and leaving the facility. Although the ADON followed the resident in her car, the resident managed to walk approximately 0.5 miles and cross a busy two-lane road. The facility staff, including the Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA), failed to maintain constant supervision, and the resident was eventually found by a hospice nurse and family members. Interviews with facility staff revealed inconsistencies in their accounts of the incident, with some staff members claiming the resident was never out of sight, while others acknowledged the resident was missing. The facility's policy on elopement was not effectively followed, as there was no immediate notification to the police or a coordinated search effort. The lack of documentation and communication among staff members further contributed to the failure to prevent the resident's elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in incidents involving resident-to-resident altercations. Resident #5 was subjected to abuse when Resident #6 attempted to choke and struck him on the back. This incident occurred in the bathroom of Resident #5's room and was witnessed by LVN E and other staff members. Despite Resident #6 having no prior aggressive behaviors, the facility did not have measures in place to prevent this occurrence, leading to a failure in ensuring Resident #5's safety. In another incident, Resident #2 was slapped on the upper arm by Resident #3, who was agitated by Resident #2's repetitive noise. This altercation was witnessed by LVN E, who was across the room at the nurse's station. Resident #3 had a history of aggressive behavior, yet the facility's interventions were insufficient to prevent the incident. The facility's failure to monitor and manage Resident #3's behavior contributed to the abuse of Resident #2. Both incidents highlight the facility's inability to maintain a safe environment for residents, particularly those with cognitive impairments and behavioral issues. The lack of effective monitoring and intervention strategies allowed these abusive interactions to occur, placing residents at risk of physical harm and emotional distress.
Misappropriation of Resident's Debit/Credit Card by CNA/Van Driver
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically their debit/credit card, by a CNA/Van Driver. The resident, who had a diagnosis of dementia, depression, and anxiety, was moderately cognitively impaired and required assistance with decision-making. The CNA/Van Driver was observed being unusually attentive to the resident's needs, which raised suspicions. It was later confirmed that the CNA/Van Driver had taken the resident's debit/credit card and used it for personal transactions. The misappropriation was discovered through a police investigation, which revealed that the CNA/Van Driver had conducted 59 fraudulent transactions using the resident's card. The transactions were captured on camera, and the CNA/Van Driver was seen withdrawing money from an ATM. The facility's social worker and the resident's fiduciary noticed unusual transactions and took steps to close the resident's account to prevent further unauthorized access. The facility's Director of Nursing and Administrator were involved in addressing the issue once it was identified. The CNA/Van Driver was terminated from employment following the confirmation of the misappropriation by police officers. The facility had a policy in place to protect residents from abuse and misappropriation, but the incident highlighted a failure in preventing the CNA/Van Driver from exploiting the resident's financial resources.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for Resident #9 and the dining room. Resident #9's bathroom had a strong odor of urine and broken, misshaped tiles around the base of the toilet, exposing large areas of grout. Despite the maintenance supervisor being aware of the issue, the repairs had not been completed, and the bathroom continued to have an offensive odor. Housekeeping staff also noticed the odor but did not place a work order for maintenance, assuming the supervisor was already aware. The Director of Nursing (DON) and the Regional Director acknowledged the importance of maintaining a clean and odor-free environment but had not taken action to address the issue in Resident #9's bathroom. The dining room environment was also found to be lacking in comfort and homeliness. Approximately 17 residents were observed seated at plastic, folding tables that did not allow proper positioning for eating comfortably, especially for those in wheelchairs. The tables were described as institutional-like and not conducive to a pleasant dining experience. The Regional Director admitted that the plastic tables were not homelike and mentioned plans to purchase better tables, but no action had been taken yet. Interviews with staff, including an RN, housekeeping aide, maintenance supervisor, and the DON, revealed a lack of communication and follow-through on maintenance and housekeeping issues. The DON and Regional Director both emphasized the importance of a homelike environment but had not implemented policies or taken steps to ensure this standard was met. The facility's inaction in addressing these environmental deficiencies compromised the residents' quality of life and comfort.
Failure to Address Resident Grievances on Unmade Beds and Cold Food
Penalty
Summary
The facility failed to address and document the grievances raised by resident groups concerning unmade beds and cold food. During Resident Council meetings on three separate occasions, residents expressed concerns about their beds not being made daily and meals being served cold. Despite these grievances being recorded, there was no documentation on how these issues would be managed or resolved, indicating a lack of prompt action and response from the facility. Observations and interviews conducted during the survey confirmed the ongoing issues. A confidential resident's bed was observed unmade, and multiple residents reported receiving cold meal trays, consistent with their complaints during council meetings. The Dietary Manager acknowledged that a test tray was not served at the appropriate temperature, further corroborating the residents' grievances about meal quality. Interviews with facility staff, including the DON and the Activity Director, revealed a lack of effective grievance management. The DON expected grievances to be resolved by the respective departments, but the process was not effectively implemented. The Activity Director, who was responsible for documenting and distributing grievances, admitted to being new to the role and still learning the process. The facility's policy required prompt resolution of grievances, but this was not adhered to, as evidenced by the unresolved issues reported by residents.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, affecting their right to communication and potentially impacting their psychosocial well-being and quality of life. This issue was identified through interviews and record reviews, where it was noted that residents consistently reported not receiving mail on weekends during Resident Council Meetings over several months. A group interview with five residents confirmed that mail was not distributed on Saturdays, and they were unsure of the reason. The Director of Nursing (DON) and the Regional Director of Operations (RDO) acknowledged the issue, with the DON indicating that the Activity Director was believed to be responsible for mail delivery, and the RDO stating that the Administrator was expected to ensure timely mail delivery. Further investigation revealed that the local Postmaster indicated the facility did not receive mail on weekends because the business had stopped their mail, affecting resident mail delivery. The Clinical Director confirmed there was no facility policy regarding mail. The report also referenced the Texas Department of Aging and Disability Services and the HUMAN RESOURCES CODE CHAPTER 102, which state that residents have the right to send and receive unopened mail promptly. This deficiency highlights a failure in the facility's processes to uphold residents' rights to communication and privacy.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate an advance directive, specifically by not accurately updating the resident's comprehensive care plan with her code status. The resident, an elderly female with severe cognitive impairment due to Alzheimer's, was admitted with several diagnoses including atrial fibrillation, depression, and anxiety. Despite having a Do-Not-Resuscitate (DNR) order signed by a family member and notarized, the resident's care plan still indicated a full code status, which was not updated in a timely manner. Interviews with the Director of Nursing (DON) and the Regional Clinical Consultant revealed that the nursing leadership was responsible for updating care plans, and the failure to do so could have placed the resident at risk of receiving unwanted CPR. The facility's policy required that care plans be kept current and updated to reflect changes in the resident's condition and code status, but this was not adhered to in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #40, a male with dementia, depression, and paranoid schizophrenia, was identified as being at high risk of elopement. Despite physician orders indicating the need for him to reside in a secure unit, his care plan did not include any interventions related to this requirement. Observations confirmed that Resident #40 was in the secure unit, but the lack of a documented care plan posed a risk to his safety. Resident #33, a male with severe cognitive impairment and a history of smoking, also lacked a comprehensive care plan addressing his need to be in a secure unit and his smoking habits. Although he was observed smoking with staff and residing in the secure unit, there were no physician orders or care plan interventions documented for these needs. Interviews with staff, including the MDS nurse and DON, revealed a lack of awareness and oversight in ensuring that care plans were updated to reflect these critical aspects of Resident #33's care. Additionally, Resident #4, a female with dementia and a history of urinary tract infections, was receiving a prophylactic antibiotic, Macrodantin, as per physician orders. However, her care plan did not reflect this ongoing treatment. Similarly, Resident #23, a male with PTSD, did not have his diagnosis or triggers documented in his care plan, despite his acknowledgment of loud noises as a trigger. The DON and Regional Clinical Consultant confirmed that these omissions in care planning were not in line with the facility's policy, which requires care plans to be comprehensive and current to ensure appropriate care for residents.
Failure to Ensure Safety Measures and Conduct Required Assessments
Penalty
Summary
The facility failed to maintain a safe environment for Resident #38 by not ensuring the presence of a fall mat as required by her care plan. Despite the care plan and medication administration record (MAR) indicating the need for a fall mat, observations revealed that the mat was not in place. RN B admitted to signing off on the MAR without verifying the mat's presence, and the Director of Nursing (DON) confirmed that the mat should have been in place for the resident's safety. Additionally, the facility did not conduct monthly smoking assessments for Resident #12 and Resident #33, as mandated by the facility's policy. Resident #12, who was moderately cognitively impaired, and Resident #33, who had significant cognitive and communication challenges, were both identified as smokers. However, their electronic medical records lacked smoking assessments for March and April 2024. The oversight was acknowledged by RN G and the DON, who were unaware of the monthly requirement until prompted by the surveyor. The social worker, responsible for completing smoking assessments, was under the impression that these assessments were annual until the surveyor's inquiry. Upon realizing the policy required monthly assessments, the social worker conducted the necessary evaluations. The facility's policy, dated December 2017, clearly stated that smoking safety evaluations should be completed monthly and upon any change in condition, but this was not adhered to, potentially compromising resident safety.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure the timely administration of medications for four residents, leading to a deficiency in pharmaceutical services. The medications for these residents were not administered at the scheduled times as per the physician's orders. This issue was observed during a survey where the medications were given significantly later than the prescribed times, potentially affecting the therapeutic outcomes for the residents involved. Resident #11, a female with severe cognitive impairment and multiple diagnoses including seizures and high blood pressure, did not receive her medications, including Clindamycin, Eliquis, Keppra, and Vimpat, at the scheduled time of 8:30 a.m. Instead, they were administered at 10:31 a.m. Similarly, Resident #54, who has chronic pain and high blood pressure, received her medications, including Tylenol, Coreg, Gabapentin, and Isosorbide, at 10:31 a.m. instead of the scheduled 8:30 a.m. Resident #50, a male with a history of stroke and kidney disease, was also affected, receiving his Tylenol at 10:44 a.m. instead of 8:30 a.m. Lastly, Resident #55, who has dementia and bipolar disorder, received his Oxcarbazepine at 10:53 a.m. instead of the scheduled 9:00 a.m. The delay in medication administration was attributed to MA K arriving late for her shift, which was not her usual schedule, and this was noted as a recurring issue. The Director of Nursing and other staff acknowledged the importance of timely medication administration and the potential adverse effects of delays.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who was prescribed psychotropic drugs was only given those drugs when necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the facility did not follow the pharmacy's recommendation to discontinue the antipsychotic medication Seroquel (quetiapine) for a resident, resulting in the resident receiving 13 additional doses of the medication. This oversight occurred despite the physician agreeing to discontinue the medication, as indicated in the pharmacy recommendation signed on 04/25/24. The resident involved was an elderly male with diagnoses including dementia, insomnia, a left femur fracture, and weakness. His admission MDS assessment indicated severely impaired cognition. The facility's Director of Nursing (DON) acknowledged the failure to implement the physician's order to discontinue the medication, citing uncertainty about how the oversight occurred. The Regional Director also expressed that the pharmacy recommendations should have been followed through by the nursing staff, emphasizing that nurse management was responsible for ensuring the completion of these recommendations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 38% based on 16 errors out of 42 opportunities. This involved four residents who did not receive their medications at the scheduled times, as per physician orders. The errors were observed during a survey, where medications were administered late by a medication aide (MA K) due to arriving late for a shift. Resident #11, a female with severe cognitive impairment and multiple diagnoses including seizures and high blood pressure, did not receive her medications at the scheduled times. Her medications, including Buspirone, Clindamycin, Eliquis, Lasix, and Keppra, were administered at 10:31 a.m. instead of the scheduled 8:30 a.m. This delay was observed during a medication pass by MA K. Similarly, Resident #54, with moderate cognitive impairment and diagnoses of chronic pain and high blood pressure, received her medications late. Medications such as Tylenol, Coreg, Fluoxetine, Gabapentin, Isosorbide ER, and Spironolactone were administered at 10:31 a.m. instead of the scheduled 8:30 a.m. The facility's Director of Nursing (DON) and Regional Director of Operations (RDO) acknowledged the issue, noting that late administration could affect medication effectiveness and resident health.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for seven residents reviewed for food and nutrition services. During an initial tour interview, two residents reported that their meal trays were cold. A subsequent group interview with five residents confirmed that the food trays served on the halls were cold. The food temperature log indicated that the regular meat was served at 188 degrees Fahrenheit, cooked vegetables at 170 and 171 degrees Fahrenheit, and dessert at 33 degrees Fahrenheit. However, during an observation, it was noted that the resident trays and the test tray were not prepared on warmed plates using a plate warmer, which contributed to the food being served at incorrect temperatures. Interviews with the Dietary Manager, Director of Nursing (DON), and Regional Dietary Officer (RDO) revealed that there was an expectation for meals to be served at standard required temperatures to ensure palatability and prevent decreased intake and weight loss. The Dietary Manager acknowledged that the test tray tasted good but needed improvement in temperature, attributing the issue to the use of cold plates. The DON and RDO emphasized the importance of serving meals at palatable temperatures, with the responsibility shared between nursing and the dietary department. The report also noted that there was no existing policy on the palatability of food.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident reviewed for resident records. Specifically, the facility did not update the comprehensive care plan of a resident with her correct code status. The resident, who was admitted with diagnoses including Alzheimer's, atrial fibrillation, depression, and anxiety, had a significant change in status assessment indicating severe cognitive impairment. Despite having a physician order for a DNR (do not resuscitate) status, the resident's care plan still indicated a full code CPR order. Interviews with the Director of Nursing (DON) and the Regional Clinical Consultant revealed that the care plan should have been updated to reflect the resident's DNR status. The DON acknowledged that the failure to update the care plan could place the resident at risk of receiving unwanted CPR. The facility's policy requires that care plans be kept current and updated to meet the individual needs of residents, consistent with the physician's plan of care.
Infection Control Deficiencies in Resident Care and Laundry Services
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #14's indwelling urinary catheter bag was repeatedly observed lying on the floor, which is against the care plan's instructions to keep the bag off the floor to prevent infection. Despite multiple observations throughout the day, the staff, including CNA H and LVN F, did not notice or correct the issue, indicating a lack of adherence to infection control protocols. The Director of Nursing (DON) acknowledged the risk of cross-contamination and stated that all staff were responsible for infection prevention. Resident #17 received improper incontinent care from CNA H, who failed to perform hand hygiene and change gloves between clean and dirty tasks. CNA H used the same wipe inappropriately and did not follow the correct front-to-back wiping technique, which could lead to infection. The DON confirmed that the CNA did not meet the expected standards for peri care and hand hygiene, which are crucial for preventing infections. The facility's laundry services also demonstrated significant lapses in infection control. Laundry staff L was observed handling soiled linen without appropriate PPE and transporting dirty linen in an open container, which could lead to cross-contamination. Additionally, clean laundry was transported uncovered within the facility, further risking contamination. The DON and Housekeeping Supervisor acknowledged these issues, with the latter admitting a lack of specific policies regarding linen handling and distribution.
Failure to Notify Resident Representatives of Falls
Penalty
Summary
The facility failed to notify the representatives of two residents immediately following significant changes in their conditions. Resident #9, an elderly female with severe cognitive impairment and multiple health issues, experienced an unwitnessed fall resulting in a scratched eyebrow. Despite the fall and subsequent neurological checks, the facility did not inform her family member about the incident or the new injury. Similarly, Resident #39, also an elderly female with severe cognitive impairment and various health conditions, had an unwitnessed fall that caused a small bump on her forehead and bruising under her eyes. The facility did not notify her family member about the fall or the injuries sustained. Interviews with the family members of both residents confirmed that they were not informed about the falls. The responsible nurse admitted to forgetting to notify the families due to the workload and paperwork. The Director of Nursing (DON) acknowledged that the families should have been notified immediately and that it was the charge nurse's responsibility to do so. The Regional Director also emphasized the importance of notifying the residents' representatives and documenting the notifications. The facility's policy on observing, reporting, and recording changes in condition mandates notifying the resident's responsible party and documenting the notification in the clinical software. However, the facility failed to adhere to this policy, resulting in the families of Resident #9 and Resident #39 not being informed about the significant changes in their conditions following their falls.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, as observed during a survey. Resident #14, who has multiple medical conditions including schizoaffective disorder, dementia, and urinary retention requiring a catheter, was found with an uncovered catheter drainage bag visible from the hallway on multiple occasions throughout the day. This was contrary to the care plan and physician's orders, which specified that the urinary bag should be covered to maintain the resident's dignity. Interviews with staff, including LVN F and LVN A, confirmed that the urinary bag should have been covered, but it was not noticed or addressed. Resident #36, who is severely cognitively impaired and requires total dependence for most activities of daily living, was observed being fed by CNA C while the CNA was standing. This action was not in line with the facility's practice of sitting at eye level with residents during feeding to promote dignity. Interviews with other CNAs and the DON confirmed that feeding should be done at eye level to ensure the resident's dignity is maintained. Attempts to reach CNA C for further clarification were unsuccessful. The DON and Regional Director acknowledged the importance of covering urinary bags and feeding residents at eye level to preserve dignity. The facility's Resident Rights policy, dated November 2021, emphasizes treating residents with dignity, courtesy, consideration, and respect. These observations and interviews highlight the facility's failure to adhere to these standards, resulting in a deficiency in maintaining the dignity and quality of life for the residents involved.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a deficiency in accommodating the needs and preferences of residents. The resident in question, a female with dementia, depression, and a urinary tract infection, was observed on multiple occasions with her call light out of reach, under her bed. This was despite her care plan specifying that the call light should be within reach due to her history of falls and unsteady gait. The resident's family member also reported the issue to the Director of Nursing (DON), who confirmed retrieving the call light from the floor. Interviews with staff, including a CNA, RN, and the DON, revealed that it was the responsibility of all staff to ensure call lights were within reach. The staff acknowledged that failure to do so could prevent residents from calling for assistance, potentially leading to falls. The Regional Director also emphasized the importance of call lights being within reach. However, it was noted that the facility did not have a specific policy on call lights, which may have contributed to the oversight.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of medical records for two residents during medication administration. Specifically, a medication aide (MA E) left the electronic medical records (EMR) of two residents open and visible on the medication cart while she walked away to locate the residents. This action occurred during the passing of medications, which could potentially expose sensitive medical information to unauthorized individuals, including other residents and visitors. The first resident involved was an elderly female with a history of heart failure and keratoconjunctivitis. Her comprehensive care plan included interventions for visual function problems and anxiety, with specific medication orders for eye drops. During an observation, MA E left this resident's medication regimen open on the EMR while searching for her, acknowledging that this could breach privacy. The second resident was an elderly female diagnosed with major depressive disorder and weakness. Her care plan aimed to manage depression and anxiety, with prescribed medications including aspirin, buspirone, and Claritin. Similarly, MA E left this resident's medication regimen open on the EMR while entering her room, admitting uncertainty about the last privacy training. Interviews with the Director of Nursing (DON) and other staff confirmed the expectation to protect resident privacy, highlighting the facility's monitoring practices for privacy breaches.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not adhere to its policy on abuse for two residents reviewed for abuse. The facility did not report injuries of unknown origin for these residents to the Health and Human Services Commission (HHSC) as required. This failure could place residents at risk of being abused and neglected. Resident #10, a female with Alzheimer's, atrial fibrillation, depression, and anxiety, was found with bruising on her perineum. Despite the facility's policy requiring the reporting of injuries of unknown origin, the injury was not reported to HHSC. The resident had a history of falls and was found on the floor next to her bed, sitting in urine with a trash can overturned. Staff suspected the bruising was caused by the fall, but the injury was not reported as suspicious. Interviews with staff indicated that the bruising was believed to be related to the fall, and the Director of Nursing (DON) did not find the injury suspicious enough to report. Resident #36, a male with multiple diagnoses including Alzheimer's and major depressive disorder, was found with bruising of unknown origin on his buttocks and chest. The bruising was discovered during a shower with family present, and the resident denied any pain or falls. The current DON stated that typically such bruises should have been reported, but she was not in the position at the time of the incident. The previous DON could not be reached for comment. The facility's failure to report these injuries as required by their policy and state law represents a significant deficiency in their abuse prevention and reporting procedures.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframes. Specifically, the facility did not report injuries of unknown origin for two residents to the appropriate authorities, including the State Survey Agency and adult protective services, as mandated by state law. This deficiency was identified during a review of records and interviews with staff members. One resident, a female with Alzheimer's and other medical conditions, was found with bruising on her perineum. The bruising was discovered after an unwitnessed fall where the resident was found sitting on the floor next to her bed. Staff members, including an LVN and a CNA, believed the bruising was caused by the resident's fall onto a trash can. Despite the bruising being large and located in a sensitive area, it was not reported to the Health and Human Services Commission (HHSC) as required. Interviews with staff revealed that they did not find the bruising suspicious and attributed it to the fall, thus failing to report it as an injury of unknown source. Another resident, a male with severe cognitive impairment and multiple medical diagnoses, was found with bruising on his buttocks and chest. The bruising was discovered during a shower with family present, and the resident denied any falls or pain. The facility's policy requires that any injury of unknown source be reported immediately, but this was not done. The facility's Director of Nursing (DON) and other staff members did not report the bruising to the appropriate authorities, as they did not consider it suspicious. This lack of reporting could potentially place residents at risk for further neglect due to unreported and uninvestigated allegations of abuse and neglect.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, leading to a deficiency in the assessment process. Specifically, the MDS assessment inaccurately recorded a weight loss for a resident who had actually experienced a significant weight gain. The resident, a male with quadriplegia, dysphagia, anemia, and neurofibromatosis, was noted to have gained 9.3% of his body weight in the last 60 days, as documented in his care plan and confirmed by the registered dietician's progress note. Despite this, the MDS assessment incorrectly indicated a weight loss, which was acknowledged as a human error by the MDS Coordinator during an interview. The MDS Coordinator admitted to mistakenly selecting the wrong option on the assessment, resulting in the inaccurate documentation. The Director of Nursing (DON) and the Regional Director both expressed expectations for accurate MDS assessments, acknowledging that inaccuracies could lead to inappropriate interventions and affect quality measures and reimbursement. However, the facility did not have a specific policy on MDS accuracy, which may have contributed to the oversight. The deficiency was identified through interviews and record reviews, highlighting the importance of accurate assessments in meeting residents' care needs.
Failure to Monitor Diabetic Wound
Penalty
Summary
The facility failed to ensure that a resident with a diabetic wound received appropriate monitoring and care in accordance with professional standards of practice. The resident, a male with a history of metabolic encephalopathy, dementia, and type 2 diabetes mellitus, had a diabetic ulcer on his right foot. Despite having a comprehensive care plan that required regular monitoring and documentation of the wound's condition, including size, depth, and other characteristics, the facility did not perform these assessments. The resident's medical records, including podiatrist notes and weekly skin assessments, lacked necessary wound measurements, indicating a failure to track the wound's progression. Observations and interviews revealed that the treatment nurse did not keep up with the wound measurements, relying instead on the podiatrist's visits. The Director of Nursing (DON) and the Regional Director both acknowledged the importance of documenting wound measurements to track improvement or worsening of the condition. The facility's policy on skin integrity monitoring required regular assessment and documentation of skin conditions, but this was not adhered to, placing the resident at risk of complications from the unmonitored diabetic wound.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident who is a trauma survivor, specifically Resident #23. Upon admission, the facility did not complete a trauma screening for Resident #23, who has a diagnosis of post-traumatic stress disorder (PTSD) from his experiences in the Vietnam and Kuwait wars. The resident's comprehensive care plan did not reflect his PTSD diagnosis or identify any triggers, such as loud noises and water, which could lead to re-traumatization. This oversight was identified during a review of the resident's records and interviews with staff. The Social Worker (SW) acknowledged that the trauma assessment was not documented in the resident's electronic medical record until it was requested, despite having completed it earlier. The Director of Nursing (DON) and the Regional Director were unaware of the reasons for the delay in documentation and the absence of a policy on trauma-informed care. Interviews with staff, including RN B and CNA D, revealed a lack of awareness regarding the resident's PTSD diagnosis and triggers, indicating a gap in communication and documentation that could impact the quality of care provided to the resident.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and security of drugs and biologicals, specifically in the medication storage refrigerator and a medication cart. During an observation, it was noted that a medication aide left a medication cart unlocked with the keys on top while administering medications to a resident. This oversight was acknowledged by the medication aide, who admitted that the cart should have been locked and the keys kept with her to prevent unauthorized access to medications. Additionally, the facility did not provide a separately locked, permanently affixed compartment for controlled drugs in the medication room's refrigerator. A liquid Lorazepam bottle was found inside an unaffixed lock box, which could be easily removed. The Licensed Vocational Nurse (LVN) responsible for the medication room acknowledged the issue, stating that the lock box had not been reattached after a new refrigerator was purchased. The Director of Nursing (DON) and Regional Director of Operations (RDO) were unaware of these security lapses, which could lead to drug diversion.
Failure to Provide Dental Services for Lost Dentures
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident who lost his dentures. The resident, who was moderately cognitively impaired, had been readmitted to the facility with multiple medical conditions, including chronic pain and muscle wasting. Despite having a physician's order allowing for dental consults and treatment as needed, no dental referral was made for the resident after his dentures were lost. Interviews revealed that the resident's family member expressed concerns about the lack of dental services, and the resident himself indicated a desire to have his dentures replaced. The facility also lacked a policy regarding the loss or damage of dentures, which contributed to the inaction. The Social Worker acknowledged reaching out to the corporate office about the lost dentures but was informed that the facility was not responsible and that no policy existed. The Director of Nursing, who was new to the facility, was unaware of the incident and the lack of a policy. This deficiency in policy and communication led to the resident not receiving timely dental care, potentially affecting his quality of life.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as observed during a survey. Specifically, three sheet pans were found with a brown grease-like buildup in the corners, and two cast iron skillets had a significant carbon buildup on both the inside and outside surfaces. Additionally, the juice machine was observed to have a dusty buildup on its front and sides. These unsanitary conditions were noted during an initial tour of the kitchen, and the cook acknowledged that the pans were not clean enough for cooking. Interviews with facility staff, including the Director of Nursing (DON), Regional Director of Operations (RDO), and the Dietary Manager, revealed an expectation for the kitchen to be maintained according to basic sanitation standards. The Dietary Manager admitted that the cast iron skillets could not be adequately cleaned and might pose a risk of illness. A review of the facility's cleaning schedule showed that the sheet pans, cast iron skillets, and juice machine were not included in the cleaning duties. The facility's General Kitchen Sanitation policy and the Food Code emphasize the importance of maintaining clean food-contact surfaces to prevent food-borne illnesses.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was observed in the cases of two residents, who were receiving hospice care. The facility did not maintain a hospice binder for one resident, which is crucial for communication and management of care between the hospice and the facility. The binder, which should contain the resident's diagnosis, care plan, and medication list, was missing, and the facility staff were unable to locate it. Interviews with the facility's RN and the hospice RN revealed that the hospice binder is essential for documenting concerns and ensuring continuity of care. In the case of another resident, the facility failed to obtain the most recent hospice plan of care. The resident's hospice binder had not been updated with the latest care plan, which should have included orders for medications such as Xanax and acetaminophen. Interviews with the Hospice DON and the Hospice Case Manager indicated that the hospice staff were behind in updating the care plans and delivering them to the facility. The lack of updated documentation in the resident's medical record posed a risk of the resident not receiving the correct medications or care. The Director of Nursing (DON) and the Regional Director both expressed expectations that the hospice provider should keep the hospice binders updated with notes, status updates, and any order changes. However, there was no policy in place at the facility regarding hospice services, which contributed to the lack of coordination and communication between the hospice and the facility. This deficiency in maintaining updated hospice documentation and coordinating care could lead to inadequate end-of-life care for residents.
Failure in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy for a resident, specifically with the use of Zithromax. The deficiency was identified when it was found that there was no documented rationale or signs and symptoms to support the use of the antibiotic for the resident. The resident, a male with a history of metabolic encephalopathy, dementia, diabetic foot ulcer, and type 2 diabetes mellitus, was administered Zithromax without documented evidence of symptoms such as fever, cough, or upper respiratory infection that would justify its use. The progress notes during the period of antibiotic administration did not indicate any symptoms that warranted the prescription, and the comprehensive care plan did not address the antibiotic use since the resident was no longer taking it. Interviews with facility staff, including an RN, the DON, and the Regional Director, revealed that there was a lack of proper documentation regarding the resident's symptoms and the rationale for the antibiotic order. The RN acknowledged that the progress notes did not reflect the symptoms that were reportedly present, and the DON confirmed that there was no solid documentation to justify the antibiotic use. The Regional Director emphasized the importance of proper documentation to avoid unwarranted orders. The facility's policy on antibiotic stewardship requires a complete assessment and documentation when initiating antibiotics, but this protocol was not followed in this case.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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