Benbrook Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Benbrook, Texas.
- Location
- 1000 Mckinley St, Benbrook, Texas 76126
- CMS Provider Number
- 675906
- Inspections on file
- 68
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Benbrook Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
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.
Surveyors found that a medication cart on a secure male unit contained Basaglar and Lantus insulin pens that lacked required open dates, and one Lantus pen that also lacked a resident identifier, contrary to facility policy and accepted standards. Several LVNs and the interim DON confirmed that insulin must be dated when opened, labeled with the resident’s name, and discarded after 28 days, and that nurses are responsible for ensuring proper labeling and dating on their carts.
A resident with multiple comorbidities, including CKD, vascular dementia, muscle wasting, and a Stage 3 pressure injury, was care planned for potential nutritional problems and required close weight monitoring. A physician ordered weekly weights for four weeks, but review of the e-chart, MAR/TAR, vitals, and nursing notes showed no documented weights or refusals during the ordered period. Staff interviews revealed that the treatment nurse and CNAs were expected to obtain and record weights, that weekly weights were required for new admissions, and that refusals should be documented, yet no such documentation existed, resulting in an incomplete and inaccurate medical record.
A resident with dementia, ADL self-care deficits, and a sacral wound infection on antibiotic therapy was found to have dried fecal matter smeared on the bed frame during surveyor observation. The resident required substantial/maximal assistance with toileting hygiene. Facility policy required appropriate cleaning of environmental surfaces such as bedrails. The Administrator identified the substance as feces, and interviews with an LVN, a CNA, and the interim DON confirmed that nursing staff and CNAs were responsible for cleaning bodily fluids and ensuring a sanitary environment, and that they had received infection control inservices, yet the fecal contamination had not been noticed or removed before it was pointed out.
A resident with a history of stroke, cognitive and emotional deficits, and hemiplegia was care planned and assessed as totally dependent for transfers, requiring two or more staff for all bed mobility and transfers. Despite this, a CNA, who acknowledged being trained that mechanical lifts require two staff for safety, was observed transferring the resident alone from a wheelchair to bed using a mechanical lift while the Administrator was present. The CNA reported she proceeded alone because the resident became upset when his preferences were not followed and no other staff were immediately available. An LVN stated that staff were not supposed to use mechanical lifts alone and that the charge nurse was responsible for ensuring proper use, and the facility’s policy required at least two nursing assistants for mechanical lift transfers.
The facility failed to maintain an effective pest control program, resulting in one resident with cerebral palsy and moderate cognitive impairment experiencing visible gnats around his bed that interfered with his sleep, while another resident in the same room reported not being bothered. Another resident with Parkinson’s disease and moderate cognitive impairment reported recurrent roaches in her room and refrigerator and stated she had informed the Administrator. Staff acknowledged prior roach infestation in that resident’s refrigerator and reports of gnats throughout the facility. Pest control service reports over several months documented recommendations to seal openings around toilets, sinks, and doors to prevent pest access, but during a walkthrough, the surveyor found that sealing work in the affected room had not been completed and the pest control log remained blank.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, failing to ensure resident safety as required.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
Two shower rooms were found with non-operational toilets covered by clear plastic trash bags, one containing a dried brown substance resembling feces, and a large hole in the wall exposing plumbing. Staff interviews revealed that these issues had not been reported to maintenance, and both the administrator and Director of Maintenance were unaware of the problems. The facility's policy affirms residents' rights to a dignified environment, but maintenance records were not available.
Nurses and medication aides lacked consistent competency in identifying and managing overfilled sharps containers, as shown by an overfilled container in a shower room and staff interviews revealing confusion about proper procedures and responsibilities. The facility had no policies or clear training on sharps disposal, leading to inconsistent practices and a deficiency in staff competency.
A resident diagnosed with ESBL in her urine repeatedly refused to comply with physician-ordered contact isolation, continued to ambulate throughout the facility, and declined the use of a bedside commode. Despite staff education and redirection, the resident was observed in common areas and interacting with others, with no effective interventions in place to enforce isolation or monitor hand hygiene, resulting in a failure to prevent potential infection transmission.
A resident with multiple medical and behavioral diagnoses was allowed to keep smoking materials and smoke unsupervised, despite repeated incidents of using marijuana or THCA products in violation of facility policy. Staff observed and reported the resident's ongoing misuse of these substances, but the facility did not implement additional supervision or effective interventions to prevent these incidents.
A resident with severe cognitive impairment and multiple medical conditions did not have shower documentation completed for several days, with no records of showers given or refusals noted. Staff interviews confirmed the expectation for regular showers and proper documentation, but the facility's system failed to ensure records were complete and accessible.
Surveyors found unsanitary conditions in a shared bathroom, including dried feces and dirty tissue, and poor maintenance in a resident room with a nonfunctional air conditioning unit and wall openings. Staff and management acknowledged lapses in cleaning and maintenance rounds, and a resident reported ongoing discomfort and lack of timely repairs.
The facility did not provide adequate supervision for several residents while smoking, despite care plans and assessments indicating the need for supervision due to visual deficits and other health conditions. Residents were observed smoking unsupervised and keeping their own cigarettes and lighters, contrary to facility policy. Additionally, a resident with moderate cognitive impairment was found with an electric kettle in her room on a secure unit, which was not addressed in her care plan or known to staff.
A CNA took a resident's debit card and used it for both authorized and unauthorized purchases, including personal use, without proper oversight. The resident, who had moderate cognitive impairment and multiple health conditions, was unable to verify which transactions were legitimate. The incident was discovered after a family member noticed suspicious bank activity, leading to police involvement and confirmation that the CNA had the card in her possession. Staff interviews confirmed that facility policy prohibits staff from handling resident money or property.
A resident requiring substantial assistance with ADLs, including showering and personal hygiene, was observed with untrimmed, dirty fingernails and an unshaven beard. The resident expressed a desire for nail and beard care, but staff interviews revealed inconsistent provision of these services and an inability to provide the facility's ADL policy when requested.
A resident with multiple health conditions developed pressure ulcers due to the facility's failure to perform accurate skin assessments and implement adequate prevention measures. Despite being at high risk for skin breakdown, the facility did not provide timely interventions or consult with a wound care physician, leading to the resident's deterioration and hospitalization.
A resident in the Memory Care Unit with severe dementia and other health issues was found with feces on his hands, fingers, and hip due to a lack of timely incontinence care. Despite facility policy requiring checks every two hours, staff were unaware of the resident's condition until later. The resident was usually continent and able to change clothes when soiled, but was waiting for a shower and anxious for care.
A resident's call light system was found to be non-functional, failing to activate in the room, hallway, and nursing station. The resident, who required supervision for ADLs, reported the issue had persisted for over a week. Staff interviews confirmed the malfunction, and the facility's policy required routine maintenance and testing of the call system.
A resident with chronic pain missed scheduled doses of Oxycontin due to the facility's failure to timely order the medication. Despite having a care plan in place, the facility did not ensure the prescription was renewed in time, leading to missed doses and the resident experiencing anxiety. The resident was given PRN Hydrocodone, which managed his pain, but the lack of scheduled Oxycontin caused distress. Communication lapses between the facility staff and the pharmacy contributed to the issue.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks in their care. One resident had an incomplete plan addressing only nutritional issues despite complex needs, while another lacked specific goals and interventions for her conditions. Staff interviews revealed systemic issues in care planning, with delays and inconsistencies impacting resident care. The DON and ADM acknowledged the importance of timely care plan completion but were unclear on why these plans were incomplete.
The facility did not maintain the required RN coverage for 8 consecutive hours on weekends during two quarters of 2024. The DON confirmed the absence of weekend RN coverage due to the loss of their weekend RN and the inability to hire a replacement. Despite the DON's availability to meet RN needs, the facility's staffing policy mandates 24-hour availability of licensed nurses and certified nursing assistants.
A resident with severe cognitive impairment was allowed to sign a form changing her Medicare insurance without involving her designated representative, leading to difficulties in obtaining medications. Facility staff were unaware of the representative's contact information, and the facility lacked a policy on cognitive fitness for signing documents. This oversight resulted in the resident being discharged against medical advice by her frustrated representative.
A resident with severe cognitive impairment and mobility issues was found without access to his call light, which was tucked under his bed frame. Despite being at risk for falls, the resident's call light was not within reach, contrary to his care plan and facility policy. Staff interviews indicated the call light was likely moved during housekeeping and not returned to an accessible position.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple health issues, including dementia and anxiety disorder. Despite staff acknowledging the importance of timely care plans, the plan was not completed, potentially impacting the resident's care. Interviews revealed confusion over responsibility for care plan completion, with the DON and ADM noting the need for timely action.
The facility failed to maintain its garbage storage dumpster in a sanitary condition, leading to trash and debris being left outside the dumpster. Staff interviews revealed that maintenance and kitchen staff were responsible for ensuring the area was clean and the dumpster lid closed. However, the dumpster was observed overflowing, with various trash items scattered around it, posing a risk of attracting pests and causing infection control issues.
A facility failed to maintain an effective pest control program, resulting in flies and gnats in the rooms of three residents. One resident with cerebral infarction and schizophrenia reported insects in his room for two months, while another with seizures and schizoaffective disorder shared the same room and experienced discomfort. A third resident with COPD and asthma also had insects in his room for a month. The facility's pest control program did not address flying insects, focusing instead on crawling pests and rodents, leading to inadequate pest management.
A facility failed to maintain a clean and homelike environment for a resident, as a dried yellowish liquid with a strong urine smell was found on the floor of the resident's room. The resident, who was mildly cognitively impaired and required assistance, expressed discomfort due to the lack of cleanliness. Interviews with staff revealed that the housekeeping department was responsible for maintaining cleanliness, but the presence of the substance indicated a failure to adhere to the facility's cleaning policies.
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.
Improper Labeling and Dating of Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that insulin pens stored on a secure male unit medication cart were properly labeled and dated in accordance with professional standards and the facility’s own medication administration policy. During an observation of one of two medication carts, surveyors and an LVN identified a Basaglar KwikPen and a Lantus KwikPen without open dates, and another Lantus KwikPen without both a resident name and an open date. Facility policy required that multi-dose containers be dated when opened and that insulin pens be clearly labeled with the resident’s name or other identifying information prior to administration. Multiple LVNs interviewed confirmed that insulin should be dated as soon as it is opened, that opened insulin is considered expired after 28 days, and that each nurse is responsible for checking their medication cart to ensure insulin is properly labeled and dated. One LVN stated that insulin without a resident name needed to be labeled to ensure the correct resident received the medication. Another LVN stated that undated insulin could be expired and could cause residents to be hypoglycemic or hyperglycemic. The interim DON stated that nursing staff were responsible for checking their medication carts on every shift and that opened insulin was considered expired after 28 days, underscoring that the undated and unlabeled insulin pens on the cart were not in compliance with facility policy and accepted professional principles.
Failure to Document Ordered Weekly Weights for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not documenting physician‑ordered weekly weights for one resident. The resident was an elderly female with multiple diagnoses including hemiplegia/hemiparesis, vascular dementia, muscle wasting and atrophy, chronic kidney disease stage 2, and a Stage 3 pressure injury present on admission. Her admission MDS showed moderate cognitive impairment with a BIMS score of 11, and she was identified as being at risk for developing pressure ulcers. Her care plan identified a potential for nutritional problems related to chronic kidney disease, lung cancer, and a history of pneumonitis, with interventions that included monitoring, recording, and reporting signs and symptoms of malnutrition and significant weight loss. Record review showed that a physician order dated 03/12/26 directed that the resident be weighed weekly for four weeks on the day shift every Thursday for weight monitoring. Review of the resident’s electronic chart, including the March MAR/TAR and vitals tab, revealed that no weights were documented from the time the order was given on 03/12/26 through 03/31/26. Review of nursing progress notes for the same period showed no recorded weights and no documentation of refusals to be weighed. This lack of documentation occurred despite the facility’s policy requiring nursing staff to monitor and document resident weights in a format that permits comparison over time and to report significant weight changes to the physician and dietitian. Interviews with staff confirmed that weights were expected to be recorded and that weekly weights were required for new admissions and readmissions for the first four weeks. LVN A stated that weights should be recorded on the MAR/TAR and that she relied on the treatment nurse and CNAs to complete them, while also stating she was not responsible for verifying whether weights were taken or accurate. The DON stated that weights should be documented under the vitals tab and that refusals required a progress note. The treatment nurse (LVN B), identified as the weight loss monitoring nurse, reported she was responsible for monitoring resident weights, that some residents had weekly weights triggered in the e‑chart, and that she sometimes delegated weights to CNAs due to workload. The ADON stated that if weekly weights after admission were not completed, she would expect a nursing note explaining why, but no such notes were found for this resident, confirming the incomplete and inaccurate medical record.
Failure to Maintain Clean Bed Environment for Resident With Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment for a resident with dementia, ADL self-care deficits, and a sacral wound infection being treated with Bactrim DS. The resident’s care plan documented substantial/maximal assistance with toileting hygiene and an active infection of the sacral wound. During an observation, surveyors noted a brownish dried substance identified by the Administrator as feces smeared on the resident’s bed frame. The resident was not interviewable. The facility’s policy on Standard Precautions stated that environmental surfaces, including bedrails and bedside equipment, are to be appropriately cleaned. Interviews with staff confirmed that the substance on the bed frame was unsanitary and that CNAs and nursing staff were responsible for ensuring residents’ beds and environments were clean and free of bodily fluids and fecal matter. The Administrator, LVN, CNA, and interim DON each acknowledged that nursing staff were primarily responsible for cleaning body fluids from bed frames before housekeeping sanitized the area, and all recognized the risk of infection related to exposure to fecal matter. Staff also reported having been inserviced on infection control, including keeping residents’ beds clean, yet the fecal matter on the bed frame had not been identified or cleaned prior to the surveyor’s observation.
Failure to Use Required Two-Person Assistance for Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and safe use of a mechanical lift for a resident who required assistance from two staff members for all transfers. The resident was an adult male with a primary diagnosis of cerebral infarction and secondary diagnoses including bipolar disorder, encephalopathy, cognitive and emotional deficits following cerebral infarction, and hemiplegia/hemiparesis. His Interim Payment MDS showed a BIMS score of 13, indicating he was cognitively intact, and Section GG documented that he was totally dependent on staff for bed mobility and transfers, requiring assistance from two or more staff for sitting to lying, lying to sitting, sit-to-stand, chair/bed transfers, and toilet transfers. His care plan identified him as at high risk for falls and documented actual falls on two consecutive days with discoloration to his left hand. On the survey date, a CNA was observed transferring this resident alone from his wheelchair to his bed using a mechanical lift, while the Administrator was present and stated he was observing the activity to ensure safety. The resident reported that it did not bother him that only one staff member used the lift, but did not indicate how often this occurred. The CNA stated she had been properly trained, knew that mechanical lifts required two staff for safety, and acknowledged that she transferred the resident alone because he became upset if his preferences were not followed and no other staff were immediately available. An LVN on the same shift stated that staff were not supposed to use mechanical lifts alone, that the charge nurse was responsible for ensuring proper use, and that she was unaware the CNA was using the lift by herself. The Administrator stated his expectation was that mechanical lifts be used with two or more staff, and the facility’s undated “Lifting Machine, using a Mechanical Level II” policy specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure resident rooms were free of pests, specifically roaches and gnats, in two of five resident rooms reviewed. One resident with cerebral palsy, major depressive disorder, and anxiety disorder, and with moderate cognitive impairment (BIMS score of 11), reported the presence of “little black flies” around his bed. During observation, the surveyor saw gnats around this resident’s bed, and the resident stated it was hard to sleep at night because of the flies around his head. Another resident in the same room reported that the flies did not bother him. Another resident, diagnosed with Parkinson’s disease and mild neurocognitive disorder with a BIMS score of 9 indicating moderate cognitive impairment, reported that she had roaches in her room and that they kept coming back. She stated that the roaches were everywhere in her room and refrigerator and that she had spoken with the Administrator about the roaches. At the time of the surveyor’s observation of this room, no roaches were seen in the bedroom or bathroom, and the roommate denied seeing roaches recently. A separate resident reported seeing the same type of small black flies in her room but stated they did not bother her because they did not bite. Staff interviews and record review showed ongoing pest concerns and uncompleted recommendations from pest control reports. The Dietary Manager reported being told by staff that the resident with Parkinson’s had a roach problem. The Maintenance Director acknowledged that the resident’s refrigerator had previously been full of roaches and that there had been reports of gnats throughout the facility. Pest prevention service reports over several months documented recommendations for caulking and sealing around toilets and sinks and replacing worn weather stripping on doors to prevent pest access, including specific recommendations for the room shared by the resident with Parkinson’s. During a walkthrough of that room, the surveyor observed that the recommended sealing of the toilet and sink had not been completed, and a pest control log the Maintenance Director was working on was blank. The surveyor did not receive the facility’s physical environment or pest control policy before exit.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Maintain Clean and Operational Shower Room Facilities
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of three shower rooms reviewed. In the 200 Hall shower room, a large hole in the wall exposed plumbing pipes, and the toilet was covered with a clear plastic trash bag, beneath which a dried brown substance, appearing to be feces, was visible. The shower room was locked and only accessible to residents when opened by staff, but an unknown resident was observed exiting the room alone with wet hair. Staff interviews revealed that the hole had been present for several weeks and that the toilet's condition had not been reported to maintenance. Staff acknowledged that all were responsible for reporting such issues, but no maintenance request had been submitted. In the 100 Hall shower room, the toilet was also covered with a clear plastic trash bag and was non-operational. Staff were unsure how long the toilet had been broken but believed it had been reported to maintenance. The administrator and Director of Maintenance were unaware of the issues in both shower rooms and had not received any work orders. The facility's policy states that residents have the right to a dignified existence, but maintenance records were not provided to confirm any prior reporting or action.
Failure to Ensure Staff Competency in Sharps Disposal
Penalty
Summary
Licensed nurses and medication aides in the facility did not demonstrate the necessary competencies and skills to care for residents as required by their assessments and care plans. Specifically, staff were unable to properly identify when sharps containers were overfilled, as evidenced by an observation of an overfilled sharps container in the shower room that was still in use. Interviews revealed that nurses and aides had inconsistent knowledge regarding the correct fill line, responsibility for emptying sharps containers, and the procedures for safe disposal. Some staff believed containers should be changed when the lid could no longer close, while others relied on visual cues from the top of the container, and several were unaware of the manufacturer's fill line. The facility administrator and DON confirmed that there were no existing policies related to nursing competency or sharps disposal at the time of the survey. Staff training on sharps disposal was inconsistent, with some staff unable to recall when or if they had received such training. The lack of clear policies and comprehensive training led to confusion among staff about their responsibilities and the correct procedures for handling sharps containers, resulting in the observed deficiency.
Failure to Enforce Contact Isolation for Resident with ESBL
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a female resident diagnosed with ESBL (Extended-Spectrum Beta-Lactamase) in her urine. Despite physician orders for contact isolation, the resident repeatedly refused to remain in her room, declined the use of a bedside commode, and continued to ambulate throughout the facility, including attending smoking activities and visiting common areas. Staff documented multiple instances where the resident was educated on the importance of infection control and isolation, but she remained non-compliant, often removing isolation signage and disregarding staff redirection. The resident's medical history included mixed anxiety and depressed mood, heart disease with a cardiac defibrillator, hypertension, opioid dependence, and seizure disorder. She was cognitively intact according to her BIMS score but exhibited behaviors such as verbal aggression, wandering, and non-compliance with care and facility policies. Staff and the physician noted that the resident was independent with most activities of daily living, including toileting, and wore an adult brief for incontinence. However, there was no effective intervention in place to ensure she remained isolated or to monitor her hand hygiene after toileting, which was identified as a potential vector for infection transmission. Observations and interviews confirmed that the resident was frequently seen outside her room, including entering the kitchen and walking in hallways near other residents, without staff consistently present to redirect her. Staff acknowledged the resident's non-compliance and reported it to nursing, but no additional measures were implemented to enforce isolation. The facility's policy required transmission-based precautions for residents with transmissible infections, but in this case, the interventions were not effective in preventing the resident from potentially spreading ESBL to others.
Failure to Provide Adequate Supervision to Prevent Misuse of Smoking Products
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically related to the misuse of a smoking product containing THCA. The resident, a male with multiple diagnoses including COPD, bipolar disorder, hypertension, generalized anxiety disorder, and a cardiac pacemaker, was assessed as cognitively intact and required supervision with all activities of daily living. Despite documented behavioral issues such as not following the smoking policy and drug-seeking behavior, the resident was allowed to keep smoking materials and smoke unsupervised, as indicated in his care plan. Multiple progress notes and staff interviews revealed ongoing incidents where the resident was observed or suspected of using marijuana or THCA products both inside and outside the facility. Staff reported smelling marijuana on the resident and witnessing him rolling and smoking substances labeled as THCA, which he claimed to have purchased legally from a nearby store. The resident was also noted to sign himself out of the facility to smoke and would return smelling of marijuana. The facility's policy allowed residents assessed as safe smokers to keep their smoking materials, but the resident repeatedly violated designated smoking areas and times, and brought non-tobacco substances into the facility. Despite repeated violations and behavioral issues, the facility's interventions were limited to education, confiscation of visible substances, and attempts to discharge the resident, which were reversed by the state agency. The facility did not provide evidence of additional supervision or changes to the resident's care plan to address the ongoing misuse of smoking products. The facility's smoking policy required evaluation of residents' ability to smoke safely and allowed for confiscation of items in violation, but staff stated they could not search the resident's belongings without violating his rights. The facility's drug policy was requested but not provided by the time of the survey exit.
Failure to Maintain Accurate Shower Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for shower documentation. Specifically, there were no shower sheets filled out for the resident over two separate periods totaling twelve days, and the electronic medical record corroborated the absence of documentation. There was also no indication in the records that the resident refused showers during these periods. The facility's process for tracking showers involved maintaining shower sheets in a large binder, but this system did not ensure that all showers or refusals were consistently documented. The resident involved was an elderly female with severe cognitive impairment, a history of nontraumatic subarachnoid hemorrhage, anxiety disorder, unspecified dementia, hypokalemia, and lack of coordination. She required partial assistance with bathing. Interviews with staff, including the DON and a CNA, confirmed the expectation that residents receive showers three times a week and that refusals are to be documented. However, the lack of documentation for the specified periods was acknowledged by both the DON and the Administrator, who also failed to provide the facility's shower/bathing policy when requested.
Failure to Maintain Cleanliness and Timely Repairs in Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by unsanitary conditions in a shared bathroom and poor maintenance in a resident room. In the shared bathroom used by three residents with varying degrees of cognitive impairment, surveyors observed multiple brown fingerprint smears on the door frame, small brown droppings and dirty tissue on the floor, dirty footprints, a dried brown stain on the commode, a pool of dried brown substance at the base of the commode, and a ball of brown substance stuck to the wall. The DON confirmed these substances appeared to be feces and acknowledged that staff should have cleaned the area immediately. Housekeeping staff reported not being aware of the bathroom's condition and stated that it was an oversight that the restroom had not been checked during rounds. The housekeeper explained that staff typically call housekeeping to sanitize after the bulk of a mess is picked up, and that CNAs have access to cleaning supplies for such situations. The administrator and DON both stated that all staff are responsible for maintaining cleanliness and that managers are expected to check rooms and bathrooms during daily rounds, but acknowledged that this process had not been effective in this instance. In a separate incident, a resident's room was found with a nonoperational air conditioning unit covered by a blanket and a towel placed on the windowsill to block drafts. The wall behind an unoccupied bed had two openings, which the maintenance director described as dents. The resident reported that the air conditioning unit had been nonfunctional for weeks and that the wall openings had been present since a previous roommate. The maintenance director was aware of the issues but found no active work orders for repairs. The resident expressed dissatisfaction with the facility's lack of timely repairs and attention to room conditions.
Failure to Supervise Smoking and Address Environmental Hazards
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to smoking practices and environmental hazards. Four residents who were identified as smokers were not properly supervised while smoking, despite care plans and assessments indicating the need for supervision due to visual deficits or other health conditions. Observations revealed that these residents were able to access smoking areas and smoke without staff present, and were in possession of cigarettes and lighters, contrary to facility policy and staff statements that such materials should be secured and only distributed under supervision. Documentation for the residents involved showed that their care plans and smoking assessments required supervision while smoking, with some residents unable to light their own cigarettes and having visual impairments. However, interviews with staff and residents confirmed that residents routinely kept their own smoking materials and smoked unsupervised. Staff interviews indicated a lack of clarity and consistency regarding the facility's smoking policy, supervision requirements, and assessment procedures. The facility's policy required quarterly reassessment of smoking safety and direct supervision for residents with restricted privileges, but these procedures were not consistently followed. Additionally, the facility failed to address an environmental hazard when a resident on a secure unit was found to have an electric kettle in her room, which was not documented in her care plan. The resident, who had moderate cognitive impairment, stated that the kettle was sent by a family member. The presence of the kettle was not known to the administrator, and staff were not aware of its existence, indicating a lapse in environmental safety monitoring. No other policy on accident hazards was provided by the facility.
CNA Misappropriation of Resident Debit Card and Funds
Penalty
Summary
A certified nursing assistant (CNA) took a resident's debit card and used it for both authorized and unauthorized purchases, as well as personal use, without proper oversight or verification. The resident, an older female with chronic obstructive pulmonary disease, major depressive disorder, anxiety, and moderate cognitive impairment, was living on a secure unit due to elopement risk. The CNA admitted to using the card after being given the PIN by the resident, but the facility was unable to determine which purchases were for the resident and which were for the CNA's personal use. The incident came to light when the resident's family member noticed suspicious activity on the resident's bank account and notified the facility administrator and police. The police recovered the debit card from the CNA, who was found to have the card in her possession at the facility. Bank statements provided by the family member showed multiple transactions, including ATM withdrawals and purchases at gas stations and grocery stores, that were not clearly authorized by the resident. Interviews with staff revealed that facility policy strictly prohibits staff from taking or using resident property, including money or debit cards, and that staff are regularly in-serviced on abuse prevention. Staff members stated they were aware that accepting money or property from residents, even with permission, is not allowed and could be considered abuse or misappropriation. The administrator and DON confirmed that staff are not permitted to run errands or make purchases for residents using their personal funds or cards.
Failure to Provide Necessary ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the resident, a male with osteoarthritis of the knee, depression, and anxiety, required substantial to maximal assistance with showering and personal hygiene, as documented in his records. Observations revealed that his fingernails were untrimmed with a yellow-brownish substance present, and his beard was unshaven. The resident expressed a desire to have his nails cut and beard shaved, and noted that he received showers only occasionally. He was also unable to fully straighten his fingers, further limiting his ability to perform self-care. Interviews with staff indicated that CNAs were responsible for providing showers and nail care unless the resident was diabetic. Staff reported that the resident often refused showers, but could sometimes be persuaded by family members. The CNA stated that the resident did not want his beard or hair touched, while the DON confirmed that CNAs should reattempt care and notify the charge nurse if a resident refused. Despite these protocols, the resident's hygiene needs were not met, and the facility was unable to provide an ADL policy when requested by surveyors.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident did not develop pressure ulcers unless clinically unavoidable and did not provide care and services consistent with professional standards to promote healing and prevent new pressure ulcers. The resident, an elderly female with multiple health conditions including hemiplegia, COPD, and neuromuscular dysfunction of the bladder, was admitted to the facility without any pressure ulcers. However, during her stay, she developed several pressure injuries, including a stage 2 decubitus ulcer on her back and deep tissue injuries on her left hip, thigh, and sacral region. The facility's failure to perform complete and accurate skin assessments contributed to the development of these pressure injuries. Despite the resident's high risk for skin breakdown due to her medical conditions and limited mobility, the facility did not implement adequate pressure prevention measures such as an air loss mattress or skin prep for the buttocks and sacral areas. Weekly skin assessments conducted by the facility's LVN did not consistently document the condition of the resident's skin, particularly in the buttocks and sacral areas, and there was a lack of timely intervention and consultation with a wound care physician. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin condition. CNAs and nurses did not consistently report or document skin changes, and the resident missed a scheduled wound care appointment due to being out of the facility for another medical appointment. The facility's Director of Nursing and Administrator acknowledged the expectation for regular skin assessments and timely interventions, but these were not effectively implemented, leading to the resident's deterioration and subsequent hospitalization.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, resulting in the resident having feces on his hands, fingers, and hip. The resident, who resides in the Memory Care Unit, has severe unspecified dementia with behavioral disturbances, chronic lymphocytic leukemia, and essential hypertension. Despite being usually continent and able to change his clothes when soiled, the resident was found in a soiled condition by LVN A, who was unaware of the situation until entering the resident's room. The resident was not upset or concerned about his condition when informed by LVN A. The facility's policy requires staff to check residents every two hours and as needed, but this was not effectively implemented in this case. CNA B, who was responsible for the resident during the shift, confirmed the policy and noted that the resident was waiting for a shower and was anxious for care. The ADM and DON acknowledged that the resident had not received personal hygiene care before being found in the soiled state. The facility's policy emphasizes providing necessary services to maintain residents' personal hygiene, which was not adhered to in this instance.
Deficiency in Resident Call Light System
Penalty
Summary
The facility failed to ensure that the call light system in a resident's room was functioning properly, which could lead to delays in assistance and affect the resident's quality of life. The resident, a male with a primary diagnosis of spondylosis without myelopathy or radiculopathy, was admitted to the facility and had a care plan indicating a need for supervision and assistance with activities of daily living (ADLs). During an observation and interview, the resident reported that his call light had not been working for more than a week, and when tested, the in-room light, the light outside the room, and the light at the nursing station did not activate. Interviews with staff, including an LVN and the Maintenance Director, confirmed that the call light system was not functioning as intended. The LVN acknowledged the issue and stated that she would have alerted the maintenance department if she had been aware of the malfunction. The Maintenance Director mentioned that the call light system was checked daily, but could not recall who checked the resident's call light on the day of the observation. The facility's policy indicated that the resident call system should be routinely maintained and tested by the maintenance department, but the deficiency in the call light system was not addressed in a timely manner.
Failure to Timely Order and Administer Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely ordering and administration of medications for a resident, leading to missed doses of Oxycontin. The resident, a male with multiple diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and chronic pain, was dependent on scheduled Oxycontin for pain management. Despite having a care plan that emphasized the importance of administering medications as ordered, the facility did not order the resident's Oxycontin in time, resulting in missed doses on two consecutive days. The issue arose when the facility's LVN attempted to reorder the medication from the pharmacy, only to be informed that a new prescription was required. Although the LVN communicated this need to the pain management nurse practitioner, the prescription was not sent promptly, leading to a delay in medication delivery. During this period, the resident was given PRN Hydrocodone, which managed his pain, but the absence of the scheduled Oxycontin doses caused the resident anxiety and led him to call emergency services. Interviews with facility staff, including the administrator, LVN, and nurse practitioners, revealed communication breakdowns and procedural lapses in medication management. The facility's policy required medications to be reordered when a four-day supply remained, but this protocol was not followed, resulting in the resident missing critical doses of his pain medication. The facility's failure to adhere to its medication administration policies placed the resident at risk of increased pain and anxiety.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could place them at risk of not receiving necessary care and services. Resident #17, a male with severe cognitive impairment and multiple medical conditions, had an incomplete care plan that only addressed nutritional issues, despite having complex needs such as assistance with personal hygiene and medication management. Similarly, Resident #25, a female with various psychological and physical conditions, had an admission care plan lacking specific goals and interventions related to her diagnoses and medication management. Interviews with facility staff revealed systemic issues in the care planning process. The Social Worker (SW) and Licensed Vocational Nurse (LVN) A indicated that comprehensive care plans were supposed to be completed within 30 days of admission or within 7 days of the Minimum Data Set (MDS) completion. However, there were delays and inconsistencies in the process, with the SW and MDS LVN responsible for monitoring completion. LVN A mentioned that baseline assessments triggered alerts for care plan completion, but acknowledged that missing care plans could impact resident care. Further interviews with other staff, including LVN B, Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), highlighted the potential negative impact of incomplete care plans on resident care. Staff expressed concerns about not knowing residents' specific needs, such as dietary requirements, behavioral interventions, and risk factors, which could lead to inadequate care. The DON and Administrator (ADM) acknowledged the importance of timely care plan completion and the responsibility of nurse managers to ensure this, but there was a lack of clarity on why the care plans for Residents #17 and #25 were incomplete.
Failure to Maintain Required RN Coverage on Weekends
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for 8 consecutive hours, 7 days a week, during two quarters of 2024. Specifically, the facility did not have RN coverage on weekends from January to May 2024. This was confirmed through a review of the CMS Payroll-Based Journal (PBJ) reports and the facility's time-stamped records, which showed a lack of RN coverage on specified weekends in January, February, March, April, and May 2024. In an interview, the Director of Nursing (DON), who has been with the facility for 1.5 years, acknowledged the absence of RN coverage on weekends during the specified period. The DON explained that the facility lost their weekend RN and was unable to hire a replacement. Although the DON stated she made herself available to meet RN needs, the facility's staffing policy requires licensed nurses and certified nursing assistants to be available 24 hours a day to provide direct resident care services.
Failure to Recognize Resident's Right to Designate a Representative
Penalty
Summary
The facility failed to recognize and respect the rights of a resident to designate a representative, leading to a significant deficiency in resident rights. A resident with severe cognitive impairment, as indicated by a BIMS score of zero, was allowed to sign a disenrollment form to change her Medicare insurance without the involvement of her designated representative. The resident's medical records showed she had Alzheimer's dementia and was listed as her own contact, despite having a family member as an emergency contact. This oversight resulted in the resident's insurance being changed without her representative's knowledge, causing difficulties in obtaining necessary medications. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's representative. The HR/BOM admitted to changing the resident's insurance due to the facility's contractual limitations with the existing Medicare advantage plan, but did not have contact information for the resident's representative at the time. The SW, who conducted the BIMS assessment, expressed discomfort with allowing a resident with cognitive impairments to sign such forms and stated that she would typically seek out family contact information in such cases. The facility's administrator acknowledged the chaotic nature of the resident's admission and the lack of clinical information provided by the discharging facility. The facility's failure to include the resident's representative in the decision-making process led to the resident being discharged against medical advice by her representative, who was frustrated by the situation. The facility did not have a policy addressing a resident's cognitive fitness to sign documents or notifying their representative, which contributed to the oversight. This deficiency highlights the risk of residents not having their representatives included in important decisions, potentially leading to delayed treatment or a decline in condition.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, a male with severe cognitive impairment, Parkinson's disease, dementia, and mobility issues, was observed without access to his call light. The resident's care plan indicated he was at risk for falls and required the call light to be within reach to request assistance. However, during an observation, the call light was found tucked under the bed frame, out of the resident's reach, which could prevent him from calling for help when needed. Interviews with staff, including a CNA, LVN, and the Administrator, revealed that the call light was likely moved during housekeeping and not returned to an accessible position. The staff acknowledged the importance of ensuring the call light was within reach, especially given the resident's fall risk. The facility's policy requires that residents have a means to call for assistance, but this was not adhered to in this instance, as evidenced by the resident's inability to locate his call light and his reliance on yelling for help.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within the required timeframe, which is crucial for providing effective and person-centered care. The resident, a male with multiple diagnoses including cerebrovascular disease, dementia, and anxiety disorder, was admitted to the facility without a baseline care plan being completed. This oversight was identified during a review of the resident's clinical care plans, which showed no baseline care plan was started or completed from the time of admission until the date of the review. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans. The social worker indicated that the MDS nurse was responsible for completing these plans, while an LVN stated it was the nursing team's responsibility to complete them within the first two days of admission. Another LVN mentioned that care plans were reviewed weekly, and any missing plans would be reported to the DON. However, the baseline care plan for this resident was not completed, which could impact the care provided, as staff would not have the necessary information to meet the resident's needs. The DON and ADM both acknowledged the importance of timely completion of baseline care plans, with the DON stating the goal was to have them completed within 24 hours of admission. The ADM mentioned that nurse managers were responsible for ensuring timely completion. The absence of a baseline care plan for the resident could lead to inaccurate care being provided, as staff would lack critical information about the resident's needs and interventions. Despite these acknowledgments, the baseline care plan for the resident remained incomplete, highlighting a significant deficiency in the facility's care planning process.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to maintain its only garbage storage dumpster and the surrounding enclosed area in a sanitary condition, which could attract pests and pose a risk of disease to residents. During an observation, various trash items were found outside the dumpster, including used latex gloves, glass shards, broken furniture, and opened medication blister packets. Interviews with the Director of Maintenance (DM), Maintenance Technician (MTNC), and Administrator (ADM) revealed that the dumpster area was the responsibility of the maintenance and kitchen staff, who were expected to ensure that trash was not left on the ground and that the dumpster lid was kept closed. The DM and MTNC acknowledged the importance of keeping the area clean to prevent pest attraction and infection control issues. The facility's staff were instructed to notify the DM or MTNC when the dumpster was nearing full capacity so that an off-schedule pick-up could be arranged. However, the dumpster was observed to be overflowing, with trash and debris scattered around it. The ADM confirmed that the maintenance and housekeeping staff were responsible for the daily upkeep of the dumpster area and emphasized the importance of keeping the lid closed to avoid odors and pest attraction. The report also referenced the Food and Drug Administration Food Code, which outlines the requirements for storing refuse and maintaining refuse areas to prevent pest access and ensure cleanliness.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the rooms of three residents. Resident #1, a male with a history of cerebral infarction, schizophrenia, bipolar disorder, and hemiplegia, was observed in his room with approximately 10-20 gnats and 5 flies. He reported that the insects had been present for two months and had informed the staff, who acknowledged the issue but had not resolved it. Resident #2, who shared a room with Resident #1 and had diagnoses including seizures and schizoaffective disorder, was also affected by the presence of flies and gnats, which made him feel uncomfortable. Resident #3, a male with COPD, asthma, and bipolar disorder, was observed with flies and gnats in his room, which had been present for a month. The facility's pest control program, as per the service agreement with Pest Control Company A, did not include measures for flying insects, focusing instead on crawling pests and rodents. The pest control logs indicated regular treatments for crawling insects and rodents but did not address the issue of flying insects inside the facility. Interviews with staff, including the Maintenance Director and the DON, revealed that the facility was aware of the pest issue but had not effectively addressed it. The Maintenance Director acknowledged the presence of insects and mentioned that the facility contracted with a pest control company, which treated the exterior for various pests but not specifically for flying insects. The Administrator also recognized the potential hazard posed by the insects to the residents' cleanliness and homelike environment, indicating a lack of comprehensive pest control measures within the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. The resident's room had a dried yellowish liquid substance on the floor, which emitted a strong smell of urine. The resident, who was mildly cognitively impaired, wheelchair-bound, and required maximal assistance, was unsure how long the substance had been present and expressed feeling uncomfortable due to the lack of cleanliness. The resident's care plan indicated a history of incontinence and a risk for falls, necessitating prompt assistance. Interviews with facility staff revealed that the Maintenance Director, who also served as the Housekeeping Supervisor, acknowledged the responsibility of the housekeeping department to maintain cleanliness in residents' rooms. The Administrator confirmed that all staff were expected to ensure that rooms were kept clean, emphasizing that the facility should be as clean as the staff's own homes. The Administrator expressed concern that failing to maintain cleanliness would not provide a homelike environment for the residents. A review of the facility's grievance log showed previous complaints about unsanitary conditions, including feces left on the floor in a hallway. The facility's housekeeping policy outlined procedures for cleaning and disinfecting environmental surfaces, including the use of EPA-registered disinfectants and regular cleaning schedules. However, the presence of dried urine in the resident's room indicated a failure to adhere to these policies, potentially exposing residents to unsanitary living conditions.
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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