Bayou Pines Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Marque, Texas.
- Location
- 4905 Fleming Street, La Marque, Texas 77568
- CMS Provider Number
- 676223
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Bayou Pines Care Center during CMS and state inspections, most recent first.
A medication aide continued to pass medications with an expired certification after her credential lapsed, despite the facility’s requirement for a current Texas medication aide certification and a policy allowing only state-licensed or permitted staff to administer medications. Personnel and timecard records showed she worked and was observed passing medications after expiration, while registry checks reflected an expired status. The medication aide reported she was unaware her certification had expired and cited renewal payment issues, and the DON acknowledged tracking expiration dates, knowing the aide’s certification was expired, and continuing to check TULIP, which showed the certification as expired but active.
An LVN failed to perform required hand hygiene during a bedtime medication pass for two residents. Video showed the LVN entering a shared room holding two medication cups in bare hands, placing both cups on one resident’s bedside table, and administering that resident’s medications while handling the beverage straw without washing hands, using ABHS, or donning gloves. The LVN then picked up the second cup from the same bedside table and administered medications to the second resident, again without any hand hygiene, and left the room without washing hands. Record review confirmed both residents had bedtime Atorvastatin orders (one also with Gabapentin) and that these doses were documented as given by the LVN, and staffing records verified the LVN was on duty during the observed shift.
A resident with epilepsy and profound disabilities did not receive prescribed Carbamazepine due to medication packets being set aside for destruction instead of being administered. Unopened medication packets were repeatedly found by nursing staff, but concerns were not investigated, and the MAR was falsely marked as given. The facility lacked a system to document or track destroyed medications, resulting in missed doses and a seizure episode.
Staff left computer screens displaying confidential resident health information unattended and visible at the nurse's station and on a medication cart, allowing residents, visitors, and staff to view MARs and other private details. Interviews confirmed that screens were not consistently locked, and the facility could not provide a written HIPAA policy.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
A resident dependent on staff for ADLs, including toileting, was left in a soiled brief and saturated bed sheets for at least 10 hours, despite requesting assistance. The resident was not provided timely incontinence care, resulting in soiled linens, skin redness, and a lack of adherence to facility policy for necessary hygiene support.
Two newly admitted residents did not have baseline care plans developed within the required timeframe, despite having complex medical needs and cognitive impairments. Staff interviews and record reviews confirmed that baseline care plans were either missing or incomplete, leaving direct care staff without essential guidance for providing person-centered care.
A resident who was dependent on staff for ADLs, including toileting, was left in a soiled brief and bed linens saturated with urine for at least 10 hours, with incontinent care not provided until several hours later. The resident, who had limited mobility and required assistance, was not assisted in a timely manner despite requests for help, resulting in prolonged exposure to urine and redness to the buttocks.
The facility did not maintain adequate nursing staff on all halls, with observations and interviews revealing frequent short staffing, especially at night. Residents and family members reported long waits for assistance with ADLs and incontinence care, and staff confirmed ongoing difficulties in filling shifts. Management acknowledged the staffing shortages and lack of a current staffing policy, resulting in residents not consistently receiving timely care.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinent care, resulting in prolonged exposure to urine and feces, a rash, and soiled linens and clothing. Staff interviews confirmed the resident was left in this condition for several hours, and facility policy requiring checks every two hours was not followed.
Two residents with a history of recurrent UTIs did not have comprehensive, person-centered care plans addressing their condition, despite multiple documented infections and related interventions. Staff interviews and record reviews confirmed that necessary care areas, objectives, and timeframes were missing from the care plans, and facility policy requiring such planning was not followed.
The facility failed to accurately assess the functional capacities of three residents, leading to incorrect MDS assessments. One resident, with multiple health issues, was inaccurately recorded as having no oral problems despite being edentulous. Another resident, with dementia, was observed to have no teeth but was assessed as having no oral issues. A third resident, with Alzheimer's, also had no teeth and did not wear dentures due to discomfort, yet her assessment showed no oral problems. These inaccuracies were acknowledged by the MDS coordinator, who noted the assessments were done by a former staff member.
A resident with multiple mental health diagnoses, including bipolar disorder, was not referred for a Level II PASRR evaluation despite receiving new treatments. The oversight was due to an outdated PASRR Level 1 screening and a lack of familiarity with PASRR procedures among facility staff. The resident's records showed routine administration of antipsychotic and antidepressant medications, but no updated PASRR evaluation was conducted since the resident's readmission.
A facility failed to develop a comprehensive care plan for a resident with PTSD, omitting goals and interventions for cognitive behavioral therapy. Despite ongoing therapy sessions and a need for managing PTSD symptoms, the care plan lacked necessary components. Staff interviews confirmed the oversight, highlighting the importance of accurate care plans for proper resident care.
A resident with anxiety and severe cognitive impairment did not receive appropriate behavioral health services due to the facility's failure to follow up on a psychological consult ordered in the care plan. The facility lacked documentation of physician orders or referrals for psychiatric services, and staff interviews revealed a lack of awareness and follow-up on the care plan's interventions.
The facility failed to store food in accordance with professional standards, as expired Med Plus cartons and a dented can of tomato soup were found in the kitchen. The Dietary Manager removed these items but did not explain the presence of expired products. The facility's policy did not address expired or dented food items, placing residents at risk of foodborne illness.
Expired Medication Aide Certification Not Identified Before Medication Administration
Penalty
Summary
The facility failed to ensure that a medication aide had a current and valid medication aide certification before allowing her to administer medications. Personnel records showed that the medication aide was hired and that her medication aide certification expired on a specific date, yet timecard records indicated she continued working from the date of expiration through a later date. An observation documented that she was actively passing medications from the 100–400 medication cart during this period. Review of the Texas Nurse Aide Registry/Electronic Monitoring Registry showed the facility had checked the registry and that her certificate was listed as expired. The facility’s job description for a certified medication aide required a current medication administration certification from Texas, and the facility’s medication administration policy stated that only persons licensed or permitted by the state may prepare, administer, and document medications. In an interview, the medication aide stated she had been working at the facility off and on since 2015 and that her certification had been expired since December due to issues with her renewal payment. She reported that when she checked the TULIP database it showed she was still active with no new date, and she stated she did not know her certification had expired. She also stated that it was the DON’s responsibility to ensure her certification was current, although usually it was the staff member’s responsibility. In a separate interview, the DON stated she maintained a list of all medication aide certificate expiration dates and acknowledged that the medication aide’s certification had expired and that the aide continued to work while expired. The DON reported that during this time she kept checking TULIP, which showed the certification as expired but active, and acknowledged understanding the risk to residents of having a medication aide pass medications with an expired certification.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves a failure by LVN A to follow hand hygiene practices during medication administration to two residents, in violation of the facility’s infection prevention and control program. Video evidence from the evening medication pass showed LVN A entering the shared room of Resident #1 and Resident #2 holding two small clear medication cups in her bare, ungloved hands. LVN A placed both cups on Resident #1’s bedside table and, without washing her hands, using alcohol-based hand sanitizer (ABHS), or donning gloves, proceeded to administer Resident #1’s medications, including handling and maneuvering Resident #1’s beverage straw with bare hands before handing the resident the medication cup. The same video evidence showed that after administering medications to Resident #1, LVN A picked up the second medication cup from Resident #1’s bedside table and went to Resident #2’s bedside. Without performing hand hygiene or donning gloves, LVN A administered Resident #2’s medications from the same type of clear plastic administration cup and then left the room without washing her hands or using ABHS. Record review confirmed that Resident #1, an older female with peripheral vascular disease, secondary drug-induced Parkinsonism, emphysema, and moderate cognitive impairment, had orders for Atorvastatin and Gabapentin at bedtime, and that these were documented as administered by LVN A. Resident #2, an older female with pneumonia, dementia with severe cognitive impairment, and epilepsy, had a bedtime Atorvastatin order that was also documented as administered by LVN A. Staffing records confirmed LVN A was working the relevant shift when these medication administrations occurred.
Failure to Administer and Track Seizure Medication Leads to Missed Doses and Seizure
Penalty
Summary
A deficiency occurred when a resident with cerebral palsy, profound intellectual disabilities, and epilepsy did not receive her prescribed Carbamazepine as ordered. The resident, who was non-verbal, dependent on staff, and received all medications via g-tube, had her medication packets found unopened and stored in a bin for destruction rather than being administered. Multiple unopened medication packets for this resident were discovered in the medication cart and later in the DON's office, with dates indicating they should have been given. Despite these findings, the medication administration record (MAR) was marked as if the medication had been given. Nursing staff, including RNs and LVNs, reported finding these unopened medication packets on several occasions and brought the issue to the attention of the DON. However, the DON did not investigate further, relying on the MAR documentation and dismissing concerns because the resident had not recently had a seizure, according to her knowledge. There was also a lack of communication between shifts, and some staff admitted to removing unopened medication packets without reporting the issue. The pharmacy confirmed that no extra medication was sent, and the medication packets matched the physician's orders. The facility did not have a system in place to document or track the destruction of non-controlled medications, including the resident's Carbamazepine. When asked for records of destroyed medications, the DON was unable to provide documentation, stating that it was no longer required. The facility's policies required proper administration and investigation of medication errors, but these procedures were not followed, resulting in the resident missing doses of her seizure medication and experiencing a seizure episode.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
Facility staff failed to maintain personal privacy and confidentiality of residents' medical records on two of four halls reviewed. Observations revealed that computer monitors at the nurse's station, which were positioned facing outward toward walkways, were left unattended and displayed confidential health information, including medication administration records (MARs) with resident names, pictures, room numbers, and medication details. On multiple occasions, these screens were left visible to residents, visitors, and staff, including during a community event when guests and children were present in the building. Additionally, a medication cart laptop was left open and unattended in a public area, exposing resident information to passersby. Interviews with staff, including LVNs and the DON, confirmed that the facility's practice was to lock computer screens when unattended to comply with HIPAA requirements. However, staff admitted to sometimes leaving screens unlocked and visible, and the facility was unable to provide a written HIPAA policy when requested. The DON acknowledged that the physical barriers at the nurse's station were insufficient to prevent exposure of private information, and staff recognized the risk of leaving screens visible to unauthorized individuals.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or include clear, measurable goals and interventions.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with a history of acute on chronic systolic congestive heart failure and major depressive disorder, who was cognitively intact but dependent on staff for activities of daily living (ADLs) including toileting, did not receive timely incontinence care. The resident experienced a decline in condition after a hospitalization, resulting in increased dependence for ADL care. On the evening in question, the resident was left in a soiled brief and saturated bed sheets for at least 10 hours, with urine soaking through to the mattress. Observations and interviews confirmed that the resident requested assistance to use the bathroom but was told by a CNA to remain in bed for the staff's convenience, and was not provided with incontinence care in a timely manner. Staff interviews and record reviews corroborated that the resident was found in the morning with soiled linens and a soaked brief, and that the resident had redness to her buttocks. The facility's own policy required appropriate support and assistance with ADLs for residents unable to perform them independently, but this was not followed. The incident was documented through direct observation, staff and responsible party interviews, and review of video evidence, all indicating a failure to provide necessary services to maintain the resident's hygiene and dignity.
Failure to Develop Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop baseline care plans that included instructions to provide effective and person-centered care for two newly admitted residents. For one resident with multiple complex diagnoses, including hypertension, osteoarthritis, acute kidney failure, renal dialysis, heart failure, dementia, and depression, there was no evidence of a baseline care plan being developed following admission. This resident was noted to have severely impaired cognitive skills, moderate hearing difficulty, and was dependent on staff for all activities of daily living. Interviews with facility staff, including the MDS nurse, Corporate MDS, and DON, confirmed that the baseline care plan was not completed as required, and staff were unable to provide a reason for this omission. Another resident admitted with rhabdomyolysis and moderate cognitive impairment also did not have a completed baseline care plan. Record review showed an attempt to start the care plan, but it was left blank. Interviews with the MDS Coordinator and DON confirmed that the baseline care plan was either incomplete or missing, which could result in direct care staff not having the necessary information to provide appropriate care. Facility policy required that a baseline care plan be developed within 48 hours of admission to address immediate needs, but this was not followed for these residents.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident with a history of acute on chronic systolic congestive heart failure and major depressive disorder, who was cognitively intact but dependent on staff for activities of daily living (ADLs) including toileting, did not receive timely incontinence care. The resident experienced a decline in condition after a hospitalization, resulting in increased dependence for ADL care. On the evening in question, the resident was left in a soiled brief and bed linens saturated with urine for at least 10 hours, with incontinent care not provided until 6 hours after the issue was first observed. Observations and interviews confirmed that the resident's brief and sheets were soaked, and redness was noted on the buttocks. Staff interactions documented that the resident requested to use the bathroom but was told by a CNA to remain in bed for ease of care, and the resident was not assisted in a timely manner. Multiple staff interviews corroborated the lack of care, with one CNA finding the resident in a soiled state at the start of her shift. The facility's own policy required appropriate support and assistance with ADLs for residents unable to perform them independently, but this was not followed in this instance.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill set to meet the needs of residents on all four halls, as evidenced by direct observation, interviews, and record review. On multiple occasions, staffing levels were observed to be below what was posted or scheduled, with some halls having only one CNA or none at all during rounds. Residents and their family members reported long wait times for assistance, including delays in responding to call lights and incontinence care, particularly during the night shift. Staff interviews confirmed frequent short staffing, especially at night, with some staff required to stay over due to call-ins and unfilled shifts. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged ongoing staffing shortages and difficulties in filling positions, despite offering incentives and implementing on-call shifts. Multiple residents and staff described the impact of inadequate staffing, including residents being left in soiled briefs and having to wait extended periods for help with activities of daily living (ADLs). Family members and residents noted a decline in care quality following a change in facility management, with several long-term staff reportedly quitting. The facility did not have a current staffing policy in place at the time of the survey, and management confirmed awareness of the staffing issues but had not resolved them. Observations and interviews consistently indicated that the lack of adequate staffing placed residents at risk of not receiving necessary care.
Failure to Provide Timely Incontinent Care and Maintain Personal Hygiene
Penalty
Summary
A deficiency occurred when a female resident with severe cognitive impairment, multiple medical diagnoses including dementia, muscle weakness, and a history of incontinence, did not receive timely incontinent care. The resident required extensive assistance with activities of daily living (ADLs), including toileting, personal hygiene, and bed mobility, as documented in her care plan. Despite these needs, the resident was left in a soiled brief and saturated linens for more than four hours, resulting in a rash on her buttocks and thighs, and feces present in the vaginal and inner thigh areas. The incident was discovered when the resident's family member arrived and found her in this condition, noting that she had not received a scheduled bath or a change of briefs until later that day. Staff interviews confirmed that the resident was found with a soaked and soiled brief at the start of a CNA's shift, and that the family member witnessed the resident being changed. Another CNA reported that the resident's wheelchair and dress were also soiled with bowel, and that the family member had requested more frequent changes due to diarrhea. The charge nurse was unaware of the resident's condition and could not verify if the resident had been bathed as scheduled. Facility policy required staff to check incontinent residents at least every two hours and provide perineal care to maintain cleanliness and comfort, prevent infection, and observe skin condition. However, staff interviews and documentation indicated that these procedures were not followed, resulting in the resident remaining in a soiled state for an extended period.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with a history of recurrent urinary tract infections (UTIs). Both residents had multiple documented episodes of UTIs within a short period, as evidenced by infection control tracking, laboratory results, and medication administration records. Despite this, their care plans did not include any care areas, measurable objectives, or timeframes specifically addressing the management or prevention of recurrent UTIs, as confirmed by record review and staff interviews. One resident, a male with significant neurological and physical impairments, including neurogenic bladder and a history of recurrent UTIs, experienced multiple infections over several months. His care plan, last revised shortly before his discharge, did not address his recurrent UTIs, even though he received multiple courses of antibiotics and interventions such as increased hydration via a gastrostomy tube. Staff interviews confirmed that interventions like encouraging fluids and providing timely incontinent care were practiced, but these were not documented in the care plan. The Director of Nursing (DON) and MDS staff acknowledged that the care plan lacked necessary updates related to his recurrent UTIs. The second resident, a female with cognitive impairment and a history of UTIs, also had multiple documented infections and hospitalizations for UTI-related sepsis. Her care plan similarly lacked any mention of her recurrent UTIs, despite her receiving antibiotics and staff being aware of her condition. Interviews with nursing and MDS staff revealed that care plans were not consistently updated to reflect residents' recurrent UTIs, and that this omission could result in staff being unaware of necessary interventions. Facility policy required identification and care planning for residents with recurrent UTIs, but this was not followed in these cases.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to conduct accurate and comprehensive assessments of residents' functional capacities, specifically for three residents. Resident #19, a female with multiple diagnoses including heart failure and bipolar disorder, was inaccurately assessed in her annual comprehensive MDS assessment. Despite being identified as edentulous with loose and broken dentures by a dentist, her MDS assessment incorrectly indicated no oral or dental problems. Observations confirmed she had no natural teeth and experienced discomfort with her dentures. Resident #85, diagnosed with conditions such as heart failure and dementia, was also inaccurately assessed. Her MDS assessment showed no oral or dental issues, yet observations revealed she had no teeth and was unable to eat corn on the cob served during a meal. Similarly, Resident #87, with diagnoses including Alzheimer's disease and repeated falls, was inaccurately assessed. Her MDS indicated no oral problems, but observations showed she had no teeth and did not wear her dentures due to discomfort. The inaccuracies in the MDS assessments were acknowledged by the MDS coordinator, who noted that the assessments were completed by a former staff member. The facility's policy on MDS assessments emphasizes the importance of accurately describing a resident's capacity to perform daily life functions. The failure to accurately assess these residents could delay the provision of necessary services to maintain their well-being.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR review despite evidence of a newly evident mental disorder. The resident, a female with multiple diagnoses including bipolar disorder, was not referred to the state-designated authority for a PASRR evaluation after new treatments for her bipolar disorder were initiated. This oversight was identified during a review of the resident's records, which showed that the resident had been receiving antipsychotic and antidepressant medications on a routine basis. The resident's PASRR Level 1 screening, conducted in 2017, did not indicate a mental illness, and no updated PASRR evaluation had been completed since the resident's readmission to the facility. The MDS nurse, who was not employed at the facility during the initial admission, acknowledged the oversight and indicated that the resident's readmission did not trigger a new PASRR Level 1 evaluation due to the duration of hospitalization. The nurse admitted to not submitting the necessary Form 1012 or updating the PASRR Level 1 to reflect the resident's current mental health status. Interviews with facility staff revealed a lack of familiarity with PASRR requirements and procedures. The Director of Nursing (DON) admitted to not being well-versed in PASRR processes and confirmed that there was no specific corporate oversight for MDS responsibilities. The facility's policy on PASRR admission assessment coordination was reviewed, highlighting the requirement for coordination with local mental health authorities if a PASRR Level 1 screening indicates a potential mental illness.
Failure to Implement Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with PTSD, which included measurable objectives and timetables to address the resident's psychological needs. Despite the resident's active diagnosis of PTSD and ongoing cognitive behavioral therapy sessions, the care plan did not include goals or interventions related to this condition. The resident's clinical chart indicated a need for managing PTSD symptoms to improve quality of life, with a plan that included medication and therapy. However, the care plan lacked these essential components, which are necessary for addressing the resident's psychological care. Interviews with facility staff, including the MDS coordinator and the Director of Nursing, revealed that the care plan had not been updated to reflect the resident's needs for PTSD management and cognitive behavioral therapy. The MDS coordinator acknowledged the oversight and noted that the care plan's accuracy is crucial for providing proper care. The facility's policy on care plans emphasizes the importance of incorporating goals and objectives to achieve the resident's highest level of independence, yet this was not reflected in the resident's care plan.
Failure to Provide Behavioral Health Services for Resident with Anxiety
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder, specifically anxiety, and psychosocial adjustment difficulties. The resident, a female admitted with a diagnosis of anxiety, exhibited severe impaired cognition, screaming, and aggressive behaviors towards other residents. Despite these issues, the facility did not ensure that the resident received individualized behavioral health services through a person-centered care plan. The care plan, last revised in September 2018, included a psychological consult as ordered by a physician, but there was no evidence that this order was initiated or followed up on. The facility's records showed no physician order for psychological services, no progress notes regarding notifications or coordination of psychiatric services, and no documentation of any referral to psychiatric services. Interviews with the Director of Nursing and MDS staff revealed a lack of awareness and follow-up on the care plan's goals and interventions. The facility's policy on care plans, which requires goals and objectives to be reviewed and revised at least quarterly, was not adhered to, leading to a deficiency in the resident's care.
Expired and Dented Food Products Found in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by storing expired food products and dented cans in the kitchen's dry goods shelves. During a kitchen observation, surveyors found seven one-quart cartons of Med Plus with a use-by date that had passed, and a dented 16oz can of tomato soup. The Dietary Manager removed these items from the shelf but did not provide an explanation for the presence of expired food products. The Dietary Manager acknowledged that dented cans should not be used due to the risk of food poisoning. The facility Administrator confirmed that expired food products and dented cans should not be present in the kitchen. A review of the facility's policy, dated 2005, titled 'Food Service Problem,' revealed that it did not address the issue of expired food products and dented cans in the kitchen. This oversight placed residents at risk of foodborne illness.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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