Beltline Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garland, Texas.
- Location
- 106 N Beltline Rd, Garland, Texas 75040
- CMS Provider Number
- 675822
- Inspections on file
- 37
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 9 (4 serious)
Citation history
Health deficiencies cited at Beltline Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and cognitive impairment did not receive a nurse practitioner's ordered urinalysis after family members raised concerns about possible UTI symptoms. Despite repeated family requests and documentation in nursing reports, the order was not entered or completed, and communication lapses among nursing staff and leadership led to the deficiency.
Three residents experienced significant lapses in care, including a lack of neurochecks and assessment after a seizure, failure to document neurological monitoring following a fall with head injury, and no intervention or care planning for ongoing refusal of psychotropic and dementia medications, resulting in behavioral decompensation and psychiatric hospitalization.
A resident with bipolar disorder and dementia repeatedly refused psychotropic and dementia-related medications, but the facility did not assess, monitor, or implement appropriate behavioral health interventions, nor revise the care plan or initiate timely psychiatric services in response. The resident's behaviors escalated, resulting in aggression and eventual transfer to a hospital for stabilization.
A resident with severe cognitive impairment and multiple psychiatric diagnoses repeatedly refused prescribed dementia and psychotropic medications, with refusals documented but not effectively addressed by staff. The care plan lacked interventions for medication refusals and behavioral symptoms, and there was insufficient communication with the physician, psychiatric provider, and family. The resident's behaviors escalated to aggression, resulting in transfer to a psychiatric hospital, and the facility failed to provide appropriate, individualized dementia care as required.
A resident with multiple health conditions experienced a witnessed seizure, but staff did not immediately notify the physician or responsible party, nor did they perform required neurological checks or assessments. The resident remained without clinical intervention until the family observed concerning behavior via camera and requested a hospital transfer. Staff interviews and video evidence confirmed the lack of timely notification and post-seizure care, resulting in a deficiency for failure to follow notification protocols.
The facility did not ensure that two residents received required face-to-face physician visits at least every 30 days during their first 90 days after admission. One resident experienced a seizure and another had behavioral decompensation requiring psychiatric hospitalization during periods when no physician or extender visit was documented. Staff interviews revealed confusion about visit requirements and issues with documentation due to staff turnover.
Two residents did not have their blood pressure obtained or documented prior to the administration or withholding of physician-ordered antihypertensive medications with parameters, resulting in multiple missed or undocumented doses. Staff interviews confirmed that required documentation and procedures were not consistently followed, and the electronic charting system did not always enforce entry of vital signs when medications were skipped.
During a period without an assigned administrator, the facility's governing body failed to maintain oversight and operational systems, resulting in three Immediate Jeopardy events. These included lack of timely physician and family notification after a seizure, failure to complete neurological checks after a fall with head injury, and not addressing repeated psychotropic medication refusals for a resident with dementia and bipolar disorder. Staff interviews revealed confusion about administrative leadership and reporting responsibilities.
A resident with dementia and multiple medical conditions experienced a fall resulting in a head injury and hospitalization. The facility did not complete an incident report at the time of the event, failed to document the fall and follow-up care in the clinical record, and did not ensure hospital records were included after the resident's return. Staff interviews revealed confusion about documentation responsibilities and protocols, leading to incomplete and delayed recordkeeping.
A resident's prescribed Hydrocodone-Acetaminophen tablets were diverted by a medication aide in an LTC facility. The aide, who had sole access to the medication cart during the incident, failed a drug test and was terminated. The resident, with a history of cognitive decline and cancer, was at risk for unrelieved pain due to the missing medication.
The facility failed to secure four areas, including shower rooms and an activity room, leaving hazardous items and equipment accessible. Unlocked doors and unsecured mechanical lifts posed risks of injury or ingestion of hazardous materials. Staff acknowledged the oversight, despite training on safety protocols.
A facility inspection revealed improper food storage and labeling practices, including unlabeled and undated food items in the refrigerator, expired goods in the pantry, and dented cans stored with other canned goods. Interviews with staff indicated lapses in routine checks and oversight, posing a risk to residents' health.
The facility failed to maintain an effective infection control program, as RN B did not clean the glucometer between uses on multiple residents, and LVN C did not disinfect the blood pressure cuff between resident checks. Both staff members were observed using the same equipment on different residents without proper cleaning, contrary to the facility's infection control policy.
A resident with no cognitive impairment was not provided with individualized or group activities, despite expressing interest in participating in activities like bingo. The facility lacked documentation of an activities assessment and progress notes, and staff interviews revealed poor communication and coordination regarding the resident's participation in activities. The resident spent most of her time in bed watching television, leading to potential isolation.
A facility failed to ensure proper G-Tube medication administration for a resident, as the LVN did not flush the tube with water before and between medications, nor check tube placement and residuals, contrary to physician's orders and facility policy. The resident had multiple diagnoses, including respiratory failure and dysphagia.
A resident's care plan was not updated to reflect her hospice status, despite documentation indicating she was receiving hospice services. Interviews with the resident, ADON, and DON confirmed the oversight, which could affect the care provided by facility staff. The facility's policy emphasizes the importance of updating care plans to reflect changes in a resident's condition or services.
A resident was discharged from a facility without a completed medication reconciliation, as required by policy. Despite staff believing all medications were provided, the resident reported not receiving blood thinners and had to address this with her physician post-discharge. The necessary documentation was missing from the electronic records, posing a risk to the resident's continuity of care.
Failure to Complete Ordered Urinalysis Following Family Request
Penalty
Summary
The facility failed to ensure that a nurse practitioner's order for a urinalysis (UA) was completed for a resident after the resident's responsible party expressed concerns about a possible urinary tract infection (UTI). The resident, an elderly female with diagnoses including dementia, congestive heart failure, chronic kidney disease, history of stroke, and breast cancer, was noted to have moderate cognitive impairment and required substantial assistance with activities of daily living. Her care plan included interventions for bladder incontinence and monitoring for signs and symptoms of UTI, with instructions to report such symptoms to the medical provider. On a specific date, the resident's family requested a UA due to the resident expressing discomfort during urination. The Assistant Director of Nursing (ADON) documented the family's request and notified the Director of Nursing (DON), who in turn sent a message to the medical provider. The medical provider's note confirmed that an order for a UA was approved by the nurse practitioner. However, review of the resident's electronic health record revealed that no order for a UA was entered or completed. Documentation in the facility's 24-hour nurse reports over subsequent days continued to reflect the family's ongoing concerns and requests for a UA, but no action was taken to complete the test. Interviews with facility staff revealed breakdowns in communication and follow-through. The DON acknowledged missing the message regarding the UA order and stated that the ADON should have entered the order and ensured its completion. Nursing staff reported documenting the family's concerns in the 24-hour report, which was supposed to be reviewed during daily meetings, but the DON admitted she did not always review these reports herself. The medical provider confirmed that a delayed UA could place the resident at risk, and the facility's policy emphasized the resident's right to receive services included in their care plan. Despite repeated documentation and family requests, the UA was never completed, constituting a failure to provide care in accordance with professional standards and the resident's care plan.
Failure to Monitor, Assess, and Communicate After Seizure, Fall, and Medication Refusal
Penalty
Summary
The facility failed to provide necessary care and services for three residents reviewed for quality of care. For one resident with a seizure disorder, after experiencing a seizure, staff did not complete neurochecks, perform a thorough assessment, or conduct lab monitoring as required by the care plan and physician orders. There was no immediate notification to the resident's representative or physician regarding the seizure, and documentation of post-seizure monitoring was absent. Surveillance footage and interviews confirmed that staff did not intervene appropriately during or after the seizure, and the resident was later sent to the ER at the family's request due to concerns about a change in condition. Another resident who sustained a fall with a head strike and injury was not properly monitored upon return from the ER. The facility did not complete or document neurological checks as required by protocol for head injuries. Interviews with staff revealed a lack of clarity regarding the process for neurochecks and incident reporting, and the resident's hospital records were not initially available in the facility's chart. The resident was observed with a significant bruise and stitches above the eyebrow, but there was no evidence of the required post-fall neurological assessments being performed or documented. A third resident with dementia and bipolar disorder refused prescribed psychotropic and dementia medications since admission, but the facility failed to assess, intervene, or develop a plan of care in response to the ongoing medication refusal. This lack of intervention led to behavioral decompensation and ultimately required psychiatric hospitalization. The report details that these failures placed residents at risk for unmanaged medical and psychiatric conditions, with documentation and interviews confirming the lack of timely assessment, monitoring, and communication with medical providers and resident representatives.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that a resident with bipolar disorder and dementia received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident repeatedly refused prescribed psychotropic and dementia-related medications over an extended period, with documented refusals for multiple medications on numerous occasions. Despite these ongoing refusals, the facility did not assess, monitor, or implement appropriate behavioral health interventions, nor did they revise the resident's care plan to address the medication refusals. There was also a lack of timely initiation of psychological or psychiatric services in response to the refusals. The resident's behaviors escalated over time, including incidents of physical aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed inconsistent practices regarding medication refusals, with some staff attempting multiple times to administer medications and others notifying physicians or family only after repeated refusals. Documentation showed that the resident's family was not informed about the consistent medication refusals, and the care plan did not include interventions to address these refusals or the resulting behavioral issues. The facility's interdisciplinary team did not effectively communicate or coordinate to address the resident's changing condition and behavioral health needs. As a result of these failures, the resident's behaviors escalated to the point of physical aggression towards another resident, leading to a transfer to an inpatient hospital for stabilization. The facility's lack of timely and appropriate response to the resident's medication refusals and behavioral health needs constituted a deficiency in providing necessary behavioral health care and services, as required by regulation.
Removal Plan
- All residents on dementia and psychotropic medications are reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
- The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
- All residents on psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
- The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee. The care plan will be updated by the DON, ADON, or MDS Nurse.
- The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.
- The medical director was notified of the immediate jeopardy citation by the administrator.
- An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
- The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.
Failure to Address Dementia Care and Medication Refusals Leads to Escalating Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in a deficiency. The resident, an elderly female with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, major depressive disorder, and insomnia, was admitted to the facility and exhibited ongoing medication refusals for her prescribed dementia and psychotropic medications. Despite repeated refusals documented in the Medication Administration Record (MAR) and nursing notes, there was no evidence that the facility adequately addressed these refusals or implemented effective interventions. The care plan did not address the resident's medication refusals or provide individualized behavioral interventions related to her dementia diagnosis. Throughout her stay, the resident displayed escalating behaviors, including aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed that medication refusals were a persistent issue, with some staff reporting that the resident had never taken medications from them and that her compliance was unpredictable. Although staff documented refusals and some behavioral incidents, there was a lack of timely notification to the physician and family, and no consistent follow-up or adjustment of interventions was documented. The resident's family was not informed of the ongoing medication refusals, and the psychiatric provider was not involved in a timely manner, with only one documented visit after admission and no clear evidence of ongoing psychiatric oversight. The resident's behaviors escalated to the point of physical aggression towards another resident, leading to her transfer to an inpatient psychiatric hospital for further evaluation. The facility's own policy required individualized, person-centered interventions and involvement of the interdisciplinary team and family in care planning, but these steps were not adequately followed. The deficiency was identified as Immediate Jeopardy due to the facility's failure to ensure the resident received necessary treatment and services to maintain her highest practicable well-being, as evidenced by untreated dementia symptoms, behavior escalation, and lack of appropriate care planning and communication.
Removal Plan
- All residents on dementia medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
- The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
- All residents with a diagnosis of dementia and/or require psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Interventions will also include pharmacological and non-pharmacological approaches to care. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
- The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The orders will include monitoring for any changes in condition after refusals. The care plan will be updated by DON, ADON, MDS or designee.
- The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director.
- Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days for dementia medications, increased or escalating behaviors.
- Dementia/Behavior Health Policy: Importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care.
- Care Plan Policy: All residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors.
- The medical director was notified of the immediate jeopardy citation by the administrator.
- An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
- In-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment.
- Monitoring the Plan of Removal implementation occurred through daily onsite visits. Facility monitoring activities included review of 24-hour reports, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services.
Failure to Notify Physician and Responsible Party After Resident Seizure
Penalty
Summary
The facility failed to notify a resident's physician and responsible party of a significant change in condition following a witnessed seizure. The resident, an elderly female with multiple comorbidities including anemia, hyperlipidemia, major depressive disorder, insomnia, hypertensive heart disease, hemiplegia, acute respiratory failure, GERD, osteoarthritis, and muscle wasting, had no documented history of seizure disorder upon admission. Despite this, she was on anticonvulsant medication and had a care plan in place for seizure management. On the morning of the incident, staff observed the resident experiencing a seizure, including foaming at the mouth and shaking, but did not immediately notify the physician or the resident's responsible party as required by facility policy and federal regulations. Following the seizure, staff failed to initiate neurological checks, perform a thorough assessment, or obtain laboratory work as outlined in the resident's care plan. Documentation in the medical record did not reflect any neurochecks or post-seizure monitoring. The responsible party and physician were not informed of the event in a timely manner. The resident remained without clinical intervention until later in the day when the family, after observing concerning behavior on a room camera, requested a hospital transfer due to the unaddressed change in condition. Interviews with staff revealed that the charge nurse did not notify the physician or responsible party, citing workload and time constraints, and the ADON and DON were under the impression that notifications had been made when they had not. Video surveillance and interviews confirmed that the resident exhibited seizure activity and post-ictal symptoms, including foaming at the mouth and minimal responsiveness, for several hours without appropriate clinical response or notification. The responsible party only became aware of the situation after viewing the camera footage and contacting the facility, at which point the resident was transferred to the hospital. The facility's failure to follow established protocols for notification and post-seizure care resulted in a deficiency, as it did not ensure timely medical evaluation or involvement of the responsible party in care decisions.
Failure to Complete Required Physician Visits Within First 90 Days of Admission
Penalty
Summary
The facility failed to ensure that required physician visits were completed at least once every 30 days during the first 90 days of admission for two residents. For one resident, who had multiple complex diagnoses including anemia, heart disease, diabetes, and severe cognitive impairment, there was no documented evidence of a face-to-face physician visit at the 30-day and 60-day marks after admission. The only recorded physician visit was on the date of admission, with subsequent visits by physician extenders, but a gap of 41 days occurred without a documented visit by either the physician or extenders. During this period, the resident experienced a seizure and was sent to the emergency room, with no immediate notification to the responsible party or physician documented in the records. Another resident, also with severe cognitive impairment and multiple psychiatric and medical diagnoses, did not have documented face-to-face physician visits as required. The resident was seen by a nurse practitioner twice shortly after admission and by the physician once, but then there was a 43-day gap without a documented visit. During this time, the resident exhibited significant behavioral issues, including aggression, medication refusals, and was ultimately transferred to the hospital for behavioral decompensation and refusal of care. Medication administration records showed frequent refusals, and nursing notes documented escalating behavioral problems. Interviews with facility staff revealed a lack of clarity regarding the required frequency of physician visits in the first 90 days post-admission. Staff described that the physician and extenders visited weekly, but there was no consistent process to ensure that all required visits were completed and properly documented. Staff turnover and issues with uploading physician visit documentation into the electronic chart were also cited as contributing factors to the deficiency.
Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, specifically for two residents reviewed for medication administration. For one resident, there were twelve occasions in July when blood pressure was not obtained or documented prior to the administration of physician-ordered antihypertensive medication with specific parameters. The medication was either not administered or marked as not available, but no blood pressure readings or vitals were recorded on the Medication Administration Record (MAR) or in nursing progress notes for those times. Another resident experienced similar issues, with blood pressure not obtained or documented prior to the administration of physician-ordered antihypertensive medications twelve times in August and seven times in September. The MAR reflected that medications were not administered or marked as not available, but again, no blood pressure readings or vitals were recorded for those administration times. Nursing progress notes for these periods also lacked corresponding blood pressure readings when medications were held. Interviews with staff revealed that facility policy required blood pressure to be checked and documented prior to administering medications with parameters, and that reasons for withholding medications should be documented in the MAR and progress notes. Staff acknowledged that sometimes documentation was missed due to being busy, and that the electronic charting system did not always enforce entry of vitals when medications were skipped. The facility's policy also required notification of the physician when a dose was not given, but this was not consistently documented.
Failure of Governing Body to Ensure Administrative Oversight and Resident Safety
Penalty
Summary
The facility's governing body failed to provide effective oversight and ensure that systems were in place to protect resident health and safety during a period when the facility operated without an assigned administrator. During this time, three Immediate Jeopardy situations occurred involving three residents. The facility did not maintain administrative oversight or monitoring systems, resulting in failures to notify physicians and responsible parties of significant changes in resident conditions, to complete required neurological checks after a fall with head injury, and to address repeated refusals of psychotropic medications for a resident with dementia and bipolar disorder. One resident, an elderly female with multiple complex medical conditions including a seizure disorder, experienced a seizure in the morning. The facility failed to promptly notify her physician and family, only sending a message to the physician in the afternoon and not informing the family until later that evening. There was no documentation of neurological monitoring or post-seizure assessment, and no evidence of follow-up physician involvement. Another resident, newly admitted with diabetes and hyperlipidemia, sustained an unwitnessed fall with a head strike and required sutures. There was no documentation of the fall in nursing progress notes, no incident report, no ER records filed, and no evidence of neurological monitoring upon her return to the facility. A third resident with severe cognitive impairment, dementia, and bipolar disorder had ongoing refusals of dementia and psychiatric medications over approximately eight weeks. Despite repeated refusals, there was no evidence of physician notification, follow-up psychiatric evaluation, or care plan interventions addressing the refusals. The resident's untreated conditions escalated to behavioral crises, resulting in transfer to a psychiatric hospital. Interviews with staff and leadership revealed confusion about who was acting as administrator, lack of clear communication, and uncertainty about who was responsible for abuse/neglect reporting and administrative oversight during the period without an assigned administrator.
Failure to Maintain Complete and Accurate Clinical Records After Resident Fall and Hospitalization
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a newly admitted female resident with diagnoses of hyperlipidemia and diabetes, who experienced a fall resulting in a head injury and subsequent hospitalization. After the resident fell, struck her head, and was sent to the emergency room due to excessive bleeding, the facility did not complete an incident report at the time of the event. The initial care plan identified the resident as being at risk for falls, with interventions in place, but there was no immediate documentation of the fall, injury assessment, or actions taken in the clinical record. Nursing progress notes for the relevant period did not contain any documentation related to the fall, and the incident report form remained incomplete until several days later, only after surveyor inquiry. Upon the resident's return from the hospital, the facility failed to ensure that her clinical record included hospital documentation from the emergency room visit. Interviews with staff revealed confusion regarding responsibility for documentation and incident reporting, as well as a lack of clarity about protocols for post-fall neurological assessments. The charge nurse on duty did not document the resident's return from the hospital or complete required neurochecks, and the hospital discharge paperwork was not immediately obtained or filed in the resident's record. The Director of Nursing later retrieved the hospital records through an online portal, but this was not done at the time of the resident's return. Observations and interviews confirmed that the resident had visible injuries, including a large bruise and sutures above her eyebrow, and that staff were aware of the fall and subsequent hospitalization. However, the lack of timely and complete documentation, including incident reports, injury assessments, and hospital records, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. This deficiency was identified through interviews, record reviews, and direct observation.
Controlled Substance Diversion in LTC Facility
Penalty
Summary
The facility failed to ensure the safety and proper management of controlled substances, leading to the diversion of 44 tablets of Hydrocodone-Acetaminophen, a Schedule II-controlled substance, prescribed to a resident. The incident occurred when Medication Aide A, who had access to the medication cart, was the only individual with access during the time the tablets went missing. The discrepancy was discovered during a medication count conducted by Charge Nurse B, who confirmed the tablets were present at the beginning of the shift but missing by the end of the shift. The resident involved was an elderly female with a history of cognitive decline, colon cancer, and abdominal swelling. She was prescribed Hydrocodone-Acetaminophen for pain management, to be administered every six hours. The medication was delivered to the facility, and one tablet was administered by Charge Nurse B before the remaining tablets were reported missing. The absence of the medication could have left the resident at risk for unrelieved pain. The facility's investigation revealed that Medication Aide A failed a drug test, testing positive for substances she was not prescribed, leading to her termination. The facility's controlled substances policy required double-lock storage and shift-change audits, which were not effectively followed, allowing the diversion to occur. The missing tablets were never recovered, and the incident was reported to the police. The resident's hospice was notified, and alternative pain management was provided.
Facility Fails to Secure Hazardous Areas and Equipment
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in four areas, including two shower rooms, an activity room, and a medical supply storage room. In the shower rooms, doors were found unlocked and ajar, with unsecured cabinets containing potentially hazardous items such as razors, mouthwash, and open bottles of cleansers. The lack of locks on these doors and cabinets posed a risk of residents accessing and potentially ingesting or injuring themselves with these items. In the activity room, both a mechanical lift and a sit-to-stand lift were observed to be unlocked and unsecured when not in use. This oversight was acknowledged by staff, who confirmed that these devices should have been locked to prevent residents from attempting to use them unsupervised, which could lead to injury. The staff admitted to being unaware of the unlocked state of these devices, despite having been trained on the importance of securing them. The medical supply storage room was also found with its door ajar and unlocked, allowing access to medical supplies such as syringes, lancets, and various medical liquids. The DON confirmed that all equipment and supplies should be locked and secured to prevent resident access, which could result in harm. Despite the facility's policies and staff training on safety, these deficiencies were observed, indicating lapses in adherence to safety protocols.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple instances of improper food storage, including unlabeled and undated food items in the refrigerator. Specifically, there were clear plastic containers of watermelon, applesauce, grated cheese, and a yellow liquid substance that were not labeled or dated. Additionally, five pans of cheesecake were found unsealed and exposed to air, which could lead to contamination. Further inspection of the facility's dry storage pantry uncovered several expired food items and improperly stored goods. There were two dented cans of dark red kidney beans stored alongside other canned goods, which is against the facility's policy. The pantry also contained expired items such as Twist Lemonade packages, Hidden Valley Ranch packages, and V8 Vegetable Juice. Open packages of pasta, cornbread mix, shredded coconut, and cornstarch were found unsealed and exposed to air, increasing the risk of contamination. Interviews with staff, including the Dietary Manager and the Administrator, highlighted a lack of awareness and oversight regarding food safety practices. The Dietary Manager acknowledged his responsibility for ensuring proper labeling, dating, and storage of food items but admitted to lapses in routine checks. The Administrator expressed surprise at the findings, noting that a recent mock survey had not raised any concerns. Despite no reported illnesses from the food served, the presence of expired and improperly stored items poses a significant risk to residents' health.
Inadequate Cleaning of Medical Equipment
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper cleaning of medical equipment between resident uses. Specifically, RN B did not clean the glucometer after checking the blood sugar levels of multiple residents. After using the glucometer on Resident #24, RN B placed it on the medication cart without cleaning it and proceeded to use the same glucometer on Resident #5 and Resident #85 without disinfecting it between uses. RN B acknowledged forgetting to clean the glucometer and admitted to having received recent training on infection control. Similarly, LVN C did not disinfect the blood pressure cuff between resident uses. After checking the blood pressure of Resident #27, LVN C used the same equipment on Resident #8 and Resident #20 without cleaning it. LVN C believed that cleaning the blood pressure machine was only necessary during a COVID-19 outbreak. The Director of Nursing (DON) confirmed that staff were expected to clean shared equipment between uses to prevent cross-contamination, as outlined in the facility's infection control policy.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized and group activities for a resident, leading to a deficiency in meeting the resident's needs for physical, mental, and psychosocial well-being. The resident, a female with a BIMS score indicating no cognitive impairment, was observed spending all her time in bed watching television and expressed a desire to participate in group activities like bingo. Despite her interest, there was no documented evidence of an activities assessment or progress notes in her clinical chart from May to November 2024. Interviews with staff revealed a lack of communication and coordination regarding the resident's participation in activities. The CNA who provided care to the resident was unaware of the need for the resident to attend group activities, and the Activity Director had not engaged the resident in any activities, citing the resident's tendency to be asleep in the mornings. The Activity Director admitted to not having assessed the resident to determine the best time for in-room activities, which contributed to the resident's isolation. The Director of Nursing (DON) and other staff members acknowledged the importance of activities in preventing isolation and maintaining the resident's quality of life. However, there was a clear disconnect between the resident's expressed interests and the facility's actions to facilitate her participation in activities. The facility's policy on informing residents and staff about activity schedules was not effectively implemented, resulting in the resident's lack of engagement in both individual and group activities.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the facility did not ensure that the Licensed Vocational Nurse (LVN) flushed the resident's gastrostomy tube (G-Tube) with 30 cc of water prior to medication administration, as per the physician's orders. Additionally, the LVN did not flush the G-Tube with 10 cc of water between each medication, nor did she check the G-Tube placement and residual during medication administration. These actions were observed during medication administration, where the LVN mixed medications with 5-10 cc of water and administered them without the required flushing or checking for residuals. The resident involved was an elderly female with multiple diagnoses, including respiratory failure, dysphagia, and gastrostomy status. The facility's policy required checking the placement of the tube by aspiration or auscultation, flushing the tube with 30 ml of water or according to physician orders, and administering one medication at a time with a flush of 5-10 ml of water between each medication. The Director of Nursing (DON) acknowledged the mistakes made by the LVN and stated that the staff were expected to follow physician's orders and facility policy to prevent complications such as G-Tube clogging and aspiration.
Failure to Update Hospice Care Plan
Penalty
Summary
The facility failed to ensure that a resident's written plan of care included the most recent hospice plan of care and a description of the services furnished by the LTC facility. This deficiency was identified for one resident who was reviewed for hospice services. The resident's care plan was not updated to reflect that she was on hospice, despite documentation in other records indicating that hospice services had begun. The resident, who had a history of dysphagia, dementia, behavioral disturbance, and other medical conditions, was receiving hospice services from a hospice company starting on a specified date. However, the care plan did not reflect this change, which was confirmed through interviews with the resident, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON). The DON acknowledged that the care plan update had been overlooked due to managing multiple residents' information. The facility's policy on comprehensive care planning emphasizes the importance of developing and implementing a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. The policy also outlines the necessity of updating care plans to reflect any changes in the resident's condition or services received, such as hospice care. The failure to update the care plan could potentially affect the care provided by the facility staff, as the care plan drives the type of care and services a resident receives.
Failure to Reconcile Medications at Discharge
Penalty
Summary
The facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications for a resident who was discharged home. This oversight was identified during a review of the resident's records and interviews with staff. The resident, who was cognitively intact and had a history of several medical conditions including hypertension and osteoarthritis, was discharged without a documented reconciliation of her medications, which included anticoagulant therapy. Interviews with staff revealed that the standard procedure for discharging a resident involved printing a medication list from the computer, reviewing it with the resident, and sending all medications home with them. However, in this case, the necessary documentation was not found in the resident's electronic clinical record. The resident reported not receiving her blood thinners upon discharge and had to address the issue with her physician afterward. Staff members, including the RN who discharged the resident, believed that all medications were provided, but no documentation could confirm this. The Director of Nursing (DON) and other staff members were unable to locate the medication reconciliation documentation in the resident's records. The facility's policy required a reconciliation of medications to be included in the discharge summary, but this was not completed. The absence of this documentation posed a risk to the resident's continuity of care and proper medication administration after discharge.
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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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