Bluebonnet Point Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Bullard, Texas.
- Location
- 151 Heritage Springs Drive, Bullard, Texas 75757
- CMS Provider Number
- 676494
- Inspections on file
- 24
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 13 (4 serious)
Citation history
Health deficiencies cited at Bluebonnet Point Wellness during CMS and state inspections, most recent first.
A cognitively intact male resident with hemiplegia, Bell’s palsy, and Type 2 DM was being assisted by an LVN to obtain a blood pressure when he moved and reached for a TV remote, requiring redirection. During this interaction, the LVN told the resident he was "acting like a 2-year-old" or "acting like a child," then removed the blood pressure cuff and left the room. The resident later reported the staff had been rude and indicated he felt very small at the time of the comment. Multiple staff, including nursing leadership and social services, described the remark as demeaning or a dignity issue, and facility policy requires that residents be treated with respect and dignity in a manner that promotes or enhances their quality of life.
A resident with a new G-tube and severe cognitive impairment experienced significant diarrhea while receiving ordered nighttime enteral feedings. On two consecutive nights, an RN independently stopped one feeding early and withheld the next scheduled nighttime feeding without notifying the MD/NP, without obtaining an order to alter the treatment, and without documenting the diarrhea or the missed/shortened feedings in the clinical record. Family video clips and CNA statements showed no feeding bag in place during the night in question, and progress notes contained no mention of diarrhea or tube feeding interruptions. Other nursing staff and the NP reported that the RN did not follow facility policy requiring immediate MD/NP notification and thorough documentation for a change in condition and alteration of ordered enteral nutrition, leading to the cited deficiency.
A resident with hemiplegia, dementia, depression, and a G-tube did not receive multiple ordered PM medications, including atorvastatin, cetirizine, melatonin, ropinirole, venlafaxine, Depakene, gabapentin, and biotin. After the resident returned from the hospital with a feeding tube, orders had been changed to G-tube administration. On a night shift, an LVN left a note listing rooms where 8:00 PM meds were given, but the resident’s room was not included. The oncoming RN misread the note, assumed the G-tube meds had been administered, did not enter the room to give them, yet signed the MAR as if all PM doses were given. Video clips and staff interviews supported that only a CNA entered the room that night. This conduct conflicted with facility policy requiring that medications be administered as ordered and documented only by the person who actually administers them, following the rights of medication administration, including right documentation.
A quarterly MDS assessment for a resident with multiple cardiac conditions and diabetes was completed but not transmitted to CMS within the required 14-day period. The assessment was submitted nine days late, with staff interviews indicating confusion over submission responsibilities and confirmation that the Corporate RN was responsible for uploading the assessment.
The facility did not ensure that a resident received an accurate assessment, resulting in incomplete or inaccurate documentation of the resident's condition and needs.
A CNA did not change gloves or perform hand hygiene between dirty and clean tasks while providing incontinent care to a resident with dementia and severe cognitive impairment. This failure to follow infection control protocol was observed and confirmed by staff interviews, in direct violation of facility policy.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A resident with moderate cognitive impairment and limited upper extremity mobility was given hot water in a cup without a lid by a medication aide, despite care plan interventions requiring lids and temperature controls for hot liquids. The resident spilled the hot liquid, resulting in a burn, and staff interviews revealed a lack of awareness about the resident's safety needs and inconsistent implementation of required interventions.
A resident with a history of blood clots did not receive Eliquis as ordered due to conflicting physician orders and a lack of medication reconciliation, resulting in the medication being held indefinitely. This led to the resident being hospitalized with acute pulmonary embolism and DVT, requiring surgical intervention. The incident was identified as Immediate Jeopardy.
A resident with multiple complex medical needs was discharged to a hospital and subsequently refused readmission by the facility due to nonpayment, resulting in the resident remaining in the hospital for over a month while alternative placement was sought. Facility records lacked evidence of discharge planning or coordination, and staff interviews indicated a lack of involvement and awareness regarding the resident's discharge process.
A resident with multiple risk factors and existing pressure injuries was not consistently repositioned or provided with appropriate pressure-relieving devices as required by her care plan and facility policy. Staff failed to offload pressure from the resident's buttock and heels, leading to the development of new stage II and stage III pressure injuries. Observations, interviews, and record reviews confirmed that staff did not follow established protocols for pressure injury prevention and care.
A resident's care plan inaccurately documented placement in a secured unit for dementia and elopement risk, even though the facility did not have a secured unit. Staff interviews confirmed the absence of such a unit and a lack of awareness about the care plan error, resulting in the resident's needs not being properly addressed according to facility policy.
A resident with urinary incontinence and mobility deficits did not receive timely assistance with personal hygiene after an incontinent episode. Staff failed to check and provide care, resulting in the resident remaining wet through breakfast. Interviews revealed assumptions about the resident's abilities and lack of adherence to skin care protocols.
Medication carts on two halls were found unlocked and unattended, with keys left accessible or carts left open, allowing unauthorized access to medications. Nursing staff acknowledged leaving the carts unsecured while attending to other tasks, and the DON confirmed that facility policy requires carts to be locked at all times unless in use.
A CNA did not perform hand hygiene or change gloves as required while providing incontinent care to a resident, including after removing soiled items, before handling clean items, and after glove removal. The CNA also used gloves that had been placed on another resident's bed and touched personal items during care without changing gloves or performing hand hygiene, contrary to facility infection control policy.
A resident with a history of dementia and other medical conditions fell and hit her head, leading to hospitalization with a subdural hematoma. The facility failed to perform necessary neurological assessments following the incident, resulting in a delay in recognizing a change in the resident's condition. Confusion among staff and incorrect incident reporting contributed to the oversight, leading to an Immediate Jeopardy situation.
Two residents in the facility did not receive adequate care for activities of daily living, resulting in deficiencies in personal hygiene. A resident with cognitive decline was found with a yellow liquid substance on his body and bed, and another resident with dementia did not receive scheduled showers. Staff interviews revealed inconsistencies in providing and documenting care, despite facility policies emphasizing the importance of hygiene for comfort and infection control.
Two CNAs at the facility failed to adhere to infection control protocols during incontinent care, leading to potential cross-contamination. CNA M did not perform hand hygiene between glove changes and touched a resident's face without changing gloves after handling soiled items. CNA X used disposable wipes multiple times, placed soiled items on a resident's bed, and did not change gloves after touching contaminated items. These actions were observed during care for two residents, highlighting lapses in infection prevention practices.
A resident with dementia and other health issues fell and hit her head, but the physician was not notified immediately, contrary to facility policy. The RN involved was new and unaware of the notification process, leading to a delay in potential medical intervention.
A resident with a history of dementia and other conditions was found on the floor after a fall, reporting a head injury. The facility failed to review hospital records promptly, leading to a delayed report of the resident's subdural hematoma to the state agency. The DON or ADON was responsible for reviewing hospital updates, which were not checked until two days after receipt, resulting in a late report.
A facility failed to involve a resident and their representative in the care planning process, despite the resident's complex medical needs and requests from the family. The social worker did not set up a care plan meeting, and the MDS Coordinator did not include the resident in the planner for care plan meetings. The facility's policy requires resident participation in care planning, which was not followed.
A facility failed to promptly address grievances from a resident's family member, who raised concerns about the lack of a care plan and COVID care. The social worker did not forward these grievances due to inexperience and misunderstanding, and the facility was undergoing staff transitions. The issues were eventually addressed by the Regional Compliance Nurse after a delay.
The facility failed to develop and communicate baseline care plans within 48 hours of admission for two residents, risking inadequate care. One resident's plan was completed on time but not communicated, while another's was completed late. Both residents had complex medical needs requiring comprehensive care plans.
A medication cart on Hall 100 was found unlocked and unattended, allowing easy access to medications. A medication aide left the cart unsecured after completing her medication pass, contrary to the facility's policy requiring secure storage accessible only to authorized personnel. The Regional Compliance Nurse confirmed the expectation for carts to be locked when unattended.
A facility failed to maintain accurate clinical records for a resident, resulting in an incorrect care plan that included hospice services no longer applicable. The resident's hospice services were revoked to pursue aggressive treatment, but the care plan continued to reflect hospice-related goals and approaches. Interviews revealed the MDS Coordinator's mistake and a lack of specific policy for maintaining accurate records.
The facility failed to complete and transmit discharge MDS assessments for two residents who were discharged to home with a status of return anticipated. The MDS Coordinators were unaware of the oversight, which was identified during interviews. The DON confirmed the expectation for timely completion and transmission of these assessments, as required by regulations.
A facility failed to document a resident's continuous oxygen therapy in their care plan, despite the resident having acute respiratory failure with hypoxia and a physician's order for oxygen use. The resident was observed using oxygen at a higher rate than prescribed, and the DON confirmed the care plan was not updated to reflect this need, potentially risking inadequate individualized care.
A resident with a PICC line did not receive a dressing change as per facility policy, which requires weekly changes using sterile technique. The dressing, dated over a week old, was observed to be loose, increasing the risk of infection. Interviews revealed confusion among nursing staff about the responsibility for changing the dressing, and the DON confirmed the absence of an order for the dressing change until after surveyor intervention.
A resident with acute respiratory failure was not administered oxygen as ordered by the physician, with the oxygen machine set at 4 liters instead of the prescribed 3 liters. The charge nurse did not verify the physician's orders, leading to the incorrect oxygen setting. The DON confirmed the error, noting the facility's policy requires verification of orders for safe oxygen administration.
A medication cart in the 400 Hall was found unlocked and unattended, exposing medications to potential unauthorized access. LVN B, responsible for the cart, forgot to lock it despite being reminded by RN F. The facility's policy mandates that all medication carts be locked when not in use, a standard reiterated by the DON.
Failure to Treat a Resident With Dignity During Blood Pressure Assessment
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and respect during routine care. A male resident with hemiplegia and hemiparesis following a cerebral infarction, Bell’s palsy, and Type 2 diabetes was cognitively intact per a recent MDS, with a BIMS score of 15 and minimal hearing difficulty. His care plan documented hemiplegia/hemiparesis related to a stroke and noted impaired cognitive function/dementia or impaired thought processes and problems communicating. Despite these conditions, he was usually able to understand and be understood by others. During an episode in which a nurse was attempting to obtain the resident’s blood pressure, the resident was moving, wiggling, and reaching for what appeared to be a TV remote, and the nurse repeatedly asked him to be still. While attempting to complete this task, the LVN told the resident he was “acting like a 2-year-old” or “acting like a child,” as confirmed by the LVN herself and by video reviewed by the administrator. After making the comment, the LVN removed the blood pressure cuff and left the room. The resident later reported that a staff member had been rude to him, agreed that she had said something close to calling him a child or 2-year-old, and stated that at the time he felt “about that tall,” indicating a small size with his fingers. Multiple staff members, including the administrator, RCN, RN, CNA, ADON, and social worker, characterized the comment as demeaning, condescending, or a dignity issue, with some staff describing such a statement as verbal abuse that must be reported. The facility’s resident rights policy states that each resident has the right to a dignified existence and must be treated with respect and dignity in a manner and environment that promotes or enhances quality of life and recognizes individuality. The LVN acknowledged making the statement and justified it by describing the resident’s behavior during care, but also stated it might have been wrong to say. This conduct constituted the failure to treat the resident with dignity and respect as required by facility policy and resident rights.
Failure to Notify Physician and Document Changes in Enteral Feeding Due to Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative of a significant change in condition and an alteration in ordered treatment related to enteral nutrition. A female resident with hemiplegia, cerebral infarction, dementia with severe cognitive impairment (BIMS score of 2), and gastrostomy status was receiving tube feeding per physician orders of Glucerna 1.2 at 65 ml/hr with water flushes. She was new to tube feeding following a recent hospital stay and had both daytime bolus feedings and continuous nighttime feedings. The resident’s care plan and orders reflected her dependence on enteral nutrition for hydration and nutrition. On two consecutive nights, the assigned RN independently altered the resident’s ordered tube feeding regimen due to the resident experiencing diarrhea, without notifying the MD/NP and without documenting the change in condition or the withheld treatment. On the first night, the RN stopped the nighttime tube feeding approximately two hours early because the resident had “bad diarrhea.” On the following night, the RN decided not to administer the ordered nighttime feeding at all, stating the resident had “massive diarrhea” and required multiple bed changes. The RN acknowledged she did not call the MD/NP at the time, did not notify them the next morning, and did not document the diarrhea, the early stoppage of the feeding, or the held feeding in the progress notes. Progress notes from other staff during this period also did not reflect diarrhea or any interruption of tube feedings, and there was no documentation of physician notification. The resident’s family, who had a motion-activated camera in the room, reported that the nighttime tube feeding was not running, prompting facility leadership to review video clips. The clips reviewed showed the resident in bed with no feeding bag on the pole and no indication of a feeding running during the relevant nighttime hours, while a CNA provided care and entered the room multiple times. The CNA assigned that night reported not seeing a feeding bag hung or running and stated the resident had multiple episodes of diarrhea since starting the new tube feeding. Interviews with the ADM, RCN, ADON, other nursing staff, and the NP confirmed that the RN did not follow facility policy requiring physician notification and documentation for a change in condition and did not obtain an order to hold the feeding. The NP stated she should have been notified of the diarrhea and that, had she been called, she likely would have agreed to stop the feeding but would have monitored the resident more closely. Facility policies on enteral nutrition and notifying the physician of a change in status required nursing to administer tube feedings as ordered, notify the physician of changes in status, and document signs and symptoms, physician contact, and resident response, which did not occur in this case. Laboratory results drawn during this period showed the resident had low sodium, and the NP later adjusted the water flushes associated with the tube feeding after being informed that a feeding had been missed and one had been stopped early. However, at the time of the events, there was no contemporaneous documentation of the resident’s diarrhea, no record of MD/NP notification, and no record of any physician orders to alter or hold the tube feeding. Interviews with other nurses indicated that their standard practice would be to immediately notify the MD/NP of diarrhea or any change in condition in a resident receiving tube feeding, to obtain orders before holding a feeding, and to document all changes and notifications. The failure to notify the physician and resident representative of the significant change in condition and the need to alter treatment, and the failure to document these changes, constituted the cited deficiency for this resident receiving enteral nutrition.
Missed G-tube Medications and False MAR Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration and documentation of multiple medications for one resident with significant medical needs. The resident was an elderly female with hemiplegia following a stroke, dementia with severe cognitive impairment (BIMS score of 2), depression, and gastrostomy status requiring tube feeding. Physician orders directed that she receive several medications via G-tube or orally, including atorvastatin for hyperlipidemia, cetirizine for allergic rhinitis, melatonin for sleep, ropinirole for restless legs syndrome, venlafaxine for depression, Depakene for migraines related to cerebral infarction, gabapentin for neuropathy, and biotin for buccal moisture. After a recent hospitalization and return with a feeding tube, her medications had been changed to G-tube administration, but the MAR still reflected these scheduled PM medications. On the night in question, there was confusion and miscommunication between two nurses regarding which medications had been administered. LVN D reported that she sometimes helped the night shift by giving only PO medications to some residents and left a written note listing specific rooms where she had given 8:00 PM medications; this list did not include the room of the resident in question. LVN D stated the resident did not have any PO medications and that it was possible RN C thought she had given the G-tube medications. CNA E, who worked the 10:00 PM to 6:00 AM shift, reported she did not specifically see RN C enter the resident’s room during that shift. Video clips from the resident’s room, which were motion-activated and not continuous, showed only a CNA entering the room around the start and near the end of the night; there was no visual evidence of either nurse entering to administer G-tube medications. RN C acknowledged that she did not administer the resident’s PM G-tube medications on that night. She stated she arrived at 10:00 PM, saw the note from LVN D, misread it, and believed that LVN D had already given the resident’s G-tube medications. Despite not administering the medications herself, RN C signed off on the MAR as though the PM doses of atorvastatin, cetirizine, melatonin, ropinirole, venlafaxine, Depakene, gabapentin, and biotin had been given. Facility staff, including other nurses and leadership, stated that checking off medications not personally administered is a medication error and contrary to nursing standards and facility policy, which requires medications to be administered as prescribed and documented by the person who actually gives them, following the rights of medication administration, including right documentation. The facility’s own Medication Administration and General Guidelines Policy specified that medications must be administered in accordance with physician orders and that the resident’s MAR is to be initialed by the person administering the medication, adhering to the rights of medication administration, including right documentation. In this case, the resident’s PM medications were not administered as ordered, and the MAR was inaccurately completed to indicate that they had been given. The facility’s internal review, including interviews with the RCN, ADM, NP, and other nursing staff, confirmed that the resident likely did not receive the ordered PM medications and that RN C documented their administration despite not providing them.
Late Submission of MDS Assessment to CMS
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) assessment was electronically transmitted to the CMS system within the required 14 days after completion for one resident. Specifically, a quarterly MDS assessment for a female resident with a history of aortocoronary bypass graft, congestive heart failure, atherosclerotic coronary heart disease, and diabetes was completed and signed by the Corporate RN Assessment Coordinator, but was not submitted to CMS until nine days past the required deadline. The MDS was completed on one date, but the submission occurred after the 14-day window, as confirmed by the CMS Submission Final Validation report, which flagged the record as submitted late. Interviews with facility staff revealed that the MDS Coordinators were not responsible for submitting the assessments and were unaware of the reason for the delay. The responsibility for uploading the MDS assessments was assigned to the RN who signed the MDS as completed. The Administrator confirmed that the expectation was for MDS assessments to be completed and transmitted as scheduled, with the Corporate RN responsible for submissions. The facility referenced the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments, which requires submission within 14 days of completion.
Failure to Provide Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete documentation of their condition and needs at the time of the survey. This inaction led to a lack of reliable information necessary for planning and delivering appropriate care to the affected resident(s).
Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a female resident with dementia and severely impaired cognition. The resident required substantial assistance with all activities of daily living and was always incontinent of bowel and bladder. During care, after cleaning the resident's pubic/groin and rectal areas, the CNA did not change gloves before placing a clean brief and applying barrier cream. Additionally, the CNA did not perform hand hygiene between glove changes, instead donning new gloves without using hand sanitizer or washing hands. Interviews with the CNA and facility leadership confirmed that the expected protocol was not followed, as staff are required to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove changes. Facility policy also specifies that gloves should be removed and hand hygiene performed before reclothing the resident. The failure to adhere to these procedures was observed directly and acknowledged by the staff involved.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Prevent Burn Injury from Hot Liquid Due to Lack of Supervision and Hazard Controls
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and limited upper extremity mobility was provided with hot water in a cup without a lid by a medication aide. The resident, who required substantial to maximal assistance with eating and had a care plan indicating a need for lids on cups containing hot liquids, spilled the hot liquid in her lap, resulting in a burn to her thigh. The medication aide was unaware of the resident's need for a lid, and the hot water was heated in a microwave without temperature verification or the use of a lid, contrary to the resident's care plan interventions. The incident was documented in nursing notes, which described the resident notifying staff after the spill, with subsequent assessment revealing a scald mark and later a blister on the thigh. The resident reported that the cup slipped from her fingers, and she did not have a lid on her mug at the time of the incident. The care plan for this resident specifically identified a risk for burns from hot liquids and required the use of a cup with a lid and temperature controls for hot beverages, but these interventions were not followed during the event. Staff interviews confirmed that, at the time, there was a lack of awareness among some staff regarding which residents required lids for hot liquids. The medication aide involved stated she was not informed of the resident's need for a lid. The facility had microwaves accessible throughout the building, and there was no system in place to ensure only authorized staff prepared hot liquids or that temperature and safety interventions were consistently implemented for at-risk residents.
Failure to Resume Anticoagulant Results in Significant Medication Error and Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with a history of pulmonary embolism and deep vein thrombosis was not administered Eliquis, an anticoagulant, as ordered by the physician. The resident was readmitted to the facility with orders to hold Eliquis for a specified period due to a scheduled polyp removal. There were two separate physician orders: one to hold Eliquis until a certain date without a restart date, and another to hold the medication for four days and restart on a specific date. The orders conflicted, and the facility's electronic system placed the medication on hold indefinitely due to the lack of a clear restart date in one of the orders. As a result of this error, the resident did not receive Eliquis for an extended period. The medication administration record (MAR) showed that Eliquis was not given from the time of readmission through the following month, with the medication remaining on hold. The facility failed to reconcile the conflicting orders and did not ensure that the medication was restarted as required by the physician's instructions. This lapse in medication administration was not identified or corrected in a timely manner. The resident was subsequently hospitalized with a diagnosis of noncompliance with Eliquis, presenting with syncope and found to have acute pulmonary embolism and right lower extremity DVT, requiring surgical intervention. The failure to administer Eliquis as ordered directly led to the resident's hospitalization and significant harm. The deficiency was identified as Immediate Jeopardy, with the noncompliance period beginning when the resident was hospitalized and ending after corrective actions were implemented.
Failure to Ensure Safe and Orderly Discharge for Resident Refused Readmission
Penalty
Summary
The facility failed to ensure a safe, orderly, and properly documented discharge for a resident who was ultimately refused readmission after a hospital stay. The resident, who had multiple medical conditions including anxiety disorder, paralysis, diabetes, amputation, cognitive decline, and housing instability, was initially given a 30-day discharge notice for nonpayment. Despite the notice and a subsequent eviction petition, the resident remained at the facility until he was sent to the hospital for shortness of breath. Upon stabilization, the hospital attempted to return the resident, but the facility refused to accept him back, citing the prior eviction for nonpayment. There was no evidence in the nursing notes or social services documentation of any discharge planning or actions to ensure the resident's needs and preferences were met prior to his hospital transfer and subsequent discharge. The facility did not coordinate with the hospital or other agencies to secure a safe and appropriate placement for the resident after his hospital stay. The resident remained in the hospital for over 30 days while the hospital social worker made numerous unsuccessful placement referrals, as the facility continued to refuse readmission. Interviews with facility staff revealed a lack of awareness and involvement in the discharge process, with the current administration attributing the actions to previous ownership. The Ombudsman was not notified or involved in the discharge, and there was no evidence of adherence to the facility's own resident rights policy, which requires equal access to care and proper discharge procedures regardless of payment source.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure injuries for a resident who was dependent on staff for repositioning and had a history of pressure injuries. The resident was admitted with multiple risk factors, including aftercare following joint replacement, type II diabetes, incontinence, and existing pressure injuries. The care plan required staff to reposition the resident every two hours and to use pressure-relieving devices, but documentation and observations showed these interventions were not consistently implemented. On multiple occasions, the resident was observed lying in bed with her buttock and heels in direct contact with the mattress, despite orders to float the heels and offload pressure areas. The resident and her family member reported that staff did not attempt to reposition her or alleviate pressure, and the family member brought in a wedge to help offload the resident's heel due to lack of staff intervention. Interviews with staff revealed a lack of awareness or mention of repositioning as part of routine care for dependent residents. As a result of these failures, the resident developed a stage II pressure injury to the right heel and a stage III pressure injury to the right buttock, neither of which were present on admission. Facility policy required regular repositioning and use of support devices to prevent pressure injuries, but these protocols were not followed, as evidenced by staff interviews, resident and family reports, and direct observations.
Failure to Accurately Develop and Implement Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected the needs and circumstances of a resident. Specifically, the care plan for one resident indicated placement in a secured care unit due to a diagnosis of dementia and risk for elopement, despite the facility not having a secured unit. This discrepancy was identified through record reviews and staff interviews, which confirmed that no secured unit existed in the facility and that no residents required such placement at the time. Interviews with the Regional Nurse and the DON revealed a lack of awareness regarding the inaccurate care plan documentation. The DON acknowledged responsibility for ensuring care plans were correct but admitted she had not reviewed care plans for references to a secured unit, as the facility did not have one. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Provide Timely Incontinent Care and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident with a history of overactive bladder, urinary incontinence, muscle weakness, unsteadiness, and difficulty walking did not receive necessary assistance with activities of daily living, specifically grooming and personal hygiene. The resident, who was moderately cognitively impaired and required substantial to maximum assistance with toileting, was observed to be wet from an incontinent episode during the morning hours. Staff interviews revealed that the certified nursing assistant (CNA) responsible for the resident had last checked on her between 6:00 a.m. and 6:15 a.m., but did not check if the resident was wet during subsequent rounds. Another nursing assistant also did not check on the resident, assuming she was able to use the bathroom independently. The resident reported frequently waiting to be changed and noted that it was unusual to have breakfast without being wet. Observations confirmed the resident's nightgown was wet up to the middle of her back. The Director of Nursing (DON) stated that staff are expected to check residents for incontinent episodes, even if they are only occasionally incontinent, to prevent skin breakdown, ensure comfort, and prevent infection. The facility did not have a specific policy regarding incontinent care, but their skin integrity management guidelines indicated that skin should be cleansed at the time of soiling and at routine intervals.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on two separate halls were left unlocked and unattended, with keys either left on top of the cart or the cart simply left open. On the 200 Hall, a medication cart was found in the hallway unlocked with the keys on top and no staff nearby. The nurse responsible for the cart stated she had been called away to assist with a resident transfer and left the cart unsecured. On the 300 Hall, two medication carts were also found unlocked, with staff walking by without securing them. The nurse responsible for these carts indicated she had left to get trash bags after completing her medication pass, leaving the carts unattended and unlocked. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for medication carts to be locked at all times unless medications are being accessed. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel. The observed failure to secure the medication carts and keys resulted in unauthorized access to medications, contrary to both facility policy and regulatory requirements.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a CNA failed to follow proper infection prevention and control protocols while providing incontinent care to a resident. The CNA entered the resident's room without performing hand hygiene, placed gloves on a roommate's bed, adjusted the bed rail, and then put on the gloves without hand hygiene. Throughout the care process, the CNA repeatedly failed to change gloves and perform hand hygiene at appropriate times, including after removing soiled items, before handling clean items, and after glove removal. The CNA also used gloves that had been placed on another resident's bed and touched personal items such as her own glasses during care without changing gloves or performing hand hygiene. Interviews with the CNA and the DON confirmed that the facility's infection control policy required hand hygiene before and after resident care, between glove changes, and when moving from clean to dirty tasks. The facility's policy also emphasized that gloves do not replace the need for hand hygiene and that failure to change gloves between resident contacts is an infection control hazard. The observed actions were inconsistent with these policies and could contribute to the transmission of communicable diseases and infections within the facility.
Failure to Conduct Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified for a resident who experienced a fall and hit her head, resulting in hospitalization with a subdural hematoma. The facility did not perform the necessary neurological assessments following the incident, which was documented in an incident report dated 1/9/25. The lack of appropriate monitoring and assessment led to a delay in recognizing a change in the resident's level of consciousness, prompting the family to request hospitalization. The resident, a female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, was admitted to the facility with a care plan indicating a risk for falls. Despite this, the facility did not conduct the required neurological checks after the resident's fall on 1/9/25. The incident report was incorrectly entered, and the electronic medical record system did not generate the necessary prompts for neurological assessments. This oversight was compounded by confusion among staff regarding the incident, as evidenced by conflicting accounts from the nurse involved and the CNA who assisted. Interviews with facility staff revealed a lack of adherence to the facility's Neurologic Checks policy, which outlines specific procedures and frequency for conducting neurological assessments after a fall or head injury. The Director of Nursing (DON) confirmed that such assessments were expected but not performed in this case. The failure to conduct these assessments and recognize the resident's change in condition resulted in an Immediate Jeopardy situation, highlighting significant lapses in the facility's care and monitoring processes.
Removal Plan
- Resident #1 had a head to toe and neurological assessment completed by the charge nurse. No change in condition noted.
- Resident #1's nurse from 1/9/25 is no longer employed with the facility.
- A neurological assessment was completed on all residents that had an unwitnessed fall or hit their heads within the last 30 days. No changes in condition were identified.
- The Administrator, DON, ADON, or designee will review all falls during the morning clinical meeting to ensure that all neuro assessments have been completed for all unwitnessed falls or residents who hit their heads.
- The Medical Director was notified of the immediate jeopardy.
- An ADHOC QAPI was completed with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.
- The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics: Abuse and Neglect Policy, Fall Prevention Policy, Neurological Assessment Policy, Incident reporting, Notification of Change in Condition Policy, Documentation.
- The following in-services were initiated by the Regional Compliance nurse, Administrator, DON, and ADON. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN staff will in-serviced prior to start of their next shift. All agency staff will in-serviced prior to their assignment.
- All Staff: Abuse and Neglect, Notification of Change in Condition Policy.
- Licensed Nurses: Abuse and Neglect Policy, Fall Prevention Policy, Incident reporting, Neuros Assessment Policy, Notification of Change in Condition Policy, Documentation.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to two residents, leading to deficiencies in personal hygiene and grooming. Resident #4, a male with cognitive decline and Guillain-Barre Syndrome, was observed with a yellow liquid substance on his mouth, gown, sheets, and blanket, indicating a lack of immediate cleaning and care. His breakfast tray was also out of reach and untouched, suggesting neglect in ensuring his needs were met. The resident was scheduled for showers three times a week but received significantly fewer showers than scheduled in November and December 2024. Resident #1, a female with dementia, anxiety, and hemiplegia, also experienced deficiencies in personal care. She was scheduled for showers three times a week but had no records of receiving showers for extended periods in January 2025. Interviews with staff revealed that CNAs were responsible for providing showers and bed baths, and nurses were to ensure these tasks were completed. However, there was a lack of documentation and follow-up when residents refused showers, and staff did not consistently clean residents when visibly dirty. The facility's policy indicated the importance of regular bathing for hygiene, comfort, and infection control. Despite this, the facility did not adhere to its policy, as evidenced by the lack of scheduled showers and immediate cleaning for the residents. Interviews with staff and the Regional Compliance Nurse highlighted expectations for shower frequency and the importance of maintaining residents' hygiene, but these expectations were not met, leading to the observed deficiencies.
Infection Control Deficiencies in CNA Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs, M and X, during the provision of incontinent care. CNA M did not perform hand hygiene between glove changes and failed to change gloves after picking up barrier cream from the floor. Additionally, CNA M touched a resident's face and swabbed her mouth without changing gloves after handling a trash bag containing soiled items. These actions were observed during care provided to Resident #2, who was receiving incontinent care. CNA X also demonstrated lapses in infection control practices while providing care to Resident #3. She used disposable wipes multiple times on the same area, placed soiled items on the resident's bed, and did not change gloves or perform hand hygiene after touching contaminated items. These actions were observed during the care of a resident with a colostomy bag, which required careful handling to prevent contamination. The facility's Regional Compliance Nurse confirmed that the CNAs did not have documented checkoffs for proper incontinent care procedures. The facility's infection control policy emphasizes the importance of hand hygiene and proper glove use to prevent the transmission of infections. The observed deficiencies in infection control practices could lead to cross-contamination and the spread of infections within the facility.
Failure to Notify Physician of Resident's Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition following a fall. The resident, an elderly female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, experienced a fall on January 9, 2025, during which she hit her head. Despite the incident being documented, the physician was not informed until the following week, which delayed potential medical intervention. The resident was moderately cognitively intact and required substantial assistance with daily activities, as indicated in her care plan. The incident report noted that the resident was found on the floor with her head against the wall, and although vital signs and a neuro assessment were conducted, the physician was not notified. An RN involved in the incident stated she did not notify the physician or the family due to being new to the facility and not knowing how to access the necessary information. The facility's policy requires immediate physician notification in the event of significant changes in a resident's condition, but this protocol was not followed, as confirmed by interviews with the Regional Compliance Nurse and the Administrator.
Delayed Reporting of Resident's Subdural Hematoma
Penalty
Summary
The facility failed to report an alleged violation involving a resident's subdural hematoma in a timely manner, as required by regulations. The resident, an elderly female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, was found on the floor by a nurse after attempting to walk to the bathroom. She reported hitting her head, and although vital signs and a neurological assessment were conducted, the incident was not immediately reported to the state agency. The resident was later admitted to the hospital with a subacute subdural hematoma, among other diagnoses. Hospital records indicating the brain bleed were uploaded to the facility's system, but the information was not reviewed by staff until two days later. The facility's Administrator reported the injury to the state agency on the same day the records were reviewed, acknowledging the delay in reporting. Interviews with facility staff revealed that the Director of Nursing (DON) or Assistant Director of Nursing (ADON) was responsible for reviewing hospital updates, which should have been done upon receipt. The failure to review these updates promptly led to a delay in reporting the subdural hematoma to the state agency, which should have been done within two hours of receiving the information. This oversight was attributed to a lack of daily review of hospital updates and communication lapses among staff responsible for monitoring hospitalized residents.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were involved in the development and implementation of a person-centered care plan. This deficiency was identified for one resident who was admitted to the facility with multiple medical conditions, including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder. The resident had a BIMS score indicating moderately impaired cognition and required substantial assistance with daily activities. Despite these needs, there was no documentation that the resident or their representative was invited to participate in care plan meetings during their stay. The facility's social worker (SW) admitted to not setting up a care plan meeting for the resident or their representative, despite receiving multiple requests from the resident's family member. The SW, who was new to the role and still learning, did not seek assistance or notify the facility's administration about the family's concerns. The SW also misunderstood the facility's responsibilities, incorrectly informing the family that the facility did not establish medical care plans. Additionally, the MDS Coordinator acknowledged that the resident's name was not included in the planner used to schedule care plan meetings. The coordinator met with the resident to complete the admission MDS assessment but did not involve the resident or their family in a formal care plan meeting. The facility's policy requires the development of a comprehensive care plan with the participation of the resident and their representative, but this was not adhered to in this case.
Failure to Address Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident, as evidenced by the lack of investigation or action taken regarding grievances voiced by the resident's family member. The resident, an elderly female with multiple medical conditions including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder, was admitted to the facility and later discharged to an acute care hospital. Despite the family member's repeated attempts to communicate concerns and request a medical care plan, the facility did not document or address these grievances. The facility's social worker (SW), who was new and under supervision, did not forward the family member's emails to the administrator or notify the Regional Compliance Nurse. The SW misunderstood the nature of the grievances, considering them as mere concerns, and failed to set up a care plan meeting due to a lack of knowledge and initiative. The facility was undergoing a change of ownership and staff transitions, which contributed to the communication breakdown and lack of response to the family's concerns. The family member's emails highlighted issues such as the absence of a care plan, lack of specific COVID care, and concerns about pneumonia prevention. The Admission Coordinator eventually forwarded the concerns to the Regional Compliance Nurse, who addressed them promptly. However, the delay in response and lack of proper grievance handling procedures were evident. Additionally, there were no postings in the facility to inform residents on how to file grievances, contrary to the facility's grievance policy.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure continuity of care and communication among staff. For Resident #1, although a baseline care plan was completed on the day of admission, there was no documentation that the resident or their representative received a summary of this plan. This resident had multiple diagnoses, including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder, which necessitated a comprehensive care plan to address these complex needs. For Resident #2, the baseline care plan was completed late, five days after admission, and similarly, there was no documentation that a summary was provided to the resident or their representative. This resident had conditions such as hemiplegia affecting the left nondominant side, hypertension, and gastroesophageal reflux disease without esophagitis. The lack of timely and communicated care plans could potentially place newly admitted residents at risk for not receiving necessary services. The Regional Compliance Nurse, who took over after a change in facility management, confirmed the absence of documentation and noted that the previous management did not ensure the provision of care plan summaries.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by an unlocked and unattended medication cart on Hall 100. During an observation, the medication cart was found against the wall, with all drawers accessible, allowing easy access to medications. This incident occurred when a medication aide, after completing her medication pass, left the cart unlocked while she went to find a nurse to count medications. The Regional Compliance Nurse confirmed that the expectation was for all medication carts to be locked when unattended. The facility's medication storage policy mandates that medications and biologicals be stored securely and only accessible to authorized personnel.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, leading to a deficiency in the comprehensive care plan. The resident, who was initially admitted for respite services under hospice care, had their hospice services revoked to pursue aggressive treatment. Despite this change, the resident's care plan continued to inaccurately reflect hospice services, including goals and approaches related to hospice care, which were no longer applicable. Interviews with facility staff revealed that the MDS Coordinator mistakenly included hospice services in the resident's care plan, despite the resident not being on hospice at the time. The Regional Compliance Nurse acknowledged the lack of a specific policy for maintaining accurate clinical records but expected care plans to reflect the resident's current status and needs. This oversight in documentation could lead to miscommunication and potential delays in services for the resident.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure that encoded, accurate, and complete Minimum Data Set (MDS) discharge assessments were electronically completed and transmitted to the CMS System within 14 days after completion for two residents. Specifically, the facility did not complete and transmit discharge MDS assessments for two residents who were discharged to home with a status of return anticipated. Both residents did not return to the facility, and their electronic medical records lacked the required discharge MDS assessments. Interviews with the MDS Coordinators revealed that they were responsible for completing these assessments but were unaware that the discharge assessments for the two residents were not completed and transmitted. The MDS Coordinators acknowledged that the assessments were missed and emphasized the importance of timely completion and transmission, as they affect quality of care measures and payments. The Director of Nursing (DON) confirmed that the MDS Coordinators were expected to complete and transmit the assessments as scheduled and required by state and federal regulations.
Failure to Document Oxygen Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not document the use of continuous oxygen therapy in the resident's care plan. The resident, who was cognitively intact, had diagnoses of hypertension, paroxysmal atrial fibrillation, and acute respiratory failure with hypoxia, and was observed using oxygen therapy set at 4 liters via nasal cannula, despite a physician's order for 3 liters. The Director of Nursing (DON) acknowledged that the care plan should have included the resident's oxygen therapy and that the care plan was not updated to reflect this need. The facility's policy requires that comprehensive, person-centered care plans include measurable objectives and timeframes and be revised as residents' conditions change. The lack of documentation for the resident's oxygen therapy in the care plan could place residents at risk of receiving inadequate interventions not individualized to their care needs.
Failure to Change PICC Line Dressing as per Policy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a Peripherally Inserted Central Catheter (PICC) line, as per professional standards of practice. The resident, who was admitted with a wedge compression fracture of the fourth lumbar vertebra, had a PICC line dressing that had not been changed since it was applied at the hospital. Observations revealed that the dressing was dated over a week old and was becoming loose, which could increase the risk of infection. Despite the facility's policy requiring weekly dressing changes using sterile technique, the resident's care plan did not address the PICC line, and there was no order for the dressing change until after surveyor intervention. Interviews with various nursing staff, including agency nurses and the Director of Nursing (DON), highlighted a lack of clarity and communication regarding the responsibility for changing the PICC line dressing. Some nurses were unsure of the facility's policy or believed it was the responsibility of an RN to perform the dressing change. The DON confirmed that the resident did not have an order for a PICC line dressing change and acknowledged the risk of infection due to the dressing not being changed in a timely manner. The facility's policy from 2001 emphasized the importance of changing dressings that were damp, loosened, or soiled, and at least every seven days to prevent catheter-related infections.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen to a resident as ordered by the physician, which was identified during observations and interviews. The resident, a cognitively intact female with diagnoses including hypertension, paroxysmal atrial fibrillation, and acute respiratory failure with hypoxia, had a physician's order for continuous oxygen at 3 liters via nasal cannula. However, during multiple observations, the resident's oxygen machine was set at 4 liters, contrary to the physician's order. The charge nurse, LVN A, admitted to not checking the resident's oxygen orders before making rounds, resulting in the incorrect oxygen setting. The Director of Nursing (DON) confirmed that the resident was administered the wrong amount of oxygen because the physician's order was not followed. The facility's Oxygen Administration policy requires verification of physician's orders for safe oxygen administration, which was not adhered to in this case.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the 400 Hall medication cart. During an observation, the medication cart was found unlocked and unsecured, with the drawers easily accessible, exposing all medications. The CNA assigned to the 400 Hall was nearby but not attending to the cart, and no residents were present in the corridor at the time. LVN B, responsible for the cart, admitted to forgetting to lock it after being reminded by RN F earlier. This oversight was attributed to it being LVN B's first day and feeling unprepared for the task. The Director of Nursing (DON) stated that the facility's policy requires all medication and treatment carts to be locked when not in use, a standard known to all LVNs. The facility's policy, revised in 2019, explicitly states that compartments containing drugs and biologicals must be locked when not in use and that unlocked medication carts should not be left unattended. The Administrator was present during the interview with the DON, reinforcing the expectation that these protocols be followed to prevent unauthorized access to medications.
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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