Brenham Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brenham, Texas.
- Location
- 1303 Hwy 290 E, Brenham, Texas 77833
- CMS Provider Number
- 676355
- Inspections on file
- 45
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 12 (4 serious)
Citation history
Health deficiencies cited at Brenham Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple serious diagnoses repeatedly refused numerous prescribed medications, including anticoagulants, psychotropics, pain medications, and nasal treatments. Although the care plan noted impaired cognition and a preference for taking pills with pudding, it did not include a specific problem, goals, or interventions for the ongoing medication refusals. MAR review showed frequent refusals, and interviews with the resident and multiple staff confirmed that the resident often declined or spit out medications, sometimes even when given chocolate pudding. Nursing staff, the DON, and the Administrator all stated that medication refusals should be care planned, and facility policy required care plans to reflect changes in condition and guide daily care, but this information was never incorporated into a comprehensive, person-centered care plan with measurable objectives and timeframes.
Surveyors found that multiple dependent residents with significant cognitive and physical impairments had extremely long, thick, discolored, and dirty fingernails and toenails, along with very dry, scaly skin on their feet and legs, despite facility records repeatedly indicating no dryness, abnormal skin, or need for nail trimming. Some residents reported that their long nails bothered them, caught on clothing, and scratched their faces, and one described his nails as very dirty and wanting them clipped. Staff interviews revealed that CNAs and nurses were expected to assess, document, and address nail and skin issues or refer residents to podiatry, but these responsibilities were inconsistently understood and not carried out, and an agency nurse admitted seeing very long nails without documenting or reporting the problem. The facility’s ADL and skin integrity policies required providing appropriate hygiene and grooming care to residents unable to perform ADLs, yet the observed nail and skin conditions and inaccurate shower documentation showed that necessary ADL services for grooming and personal hygiene were not provided.
Surveyors found that three residents with severe cognitive impairment or mobility limitations were not consistently using ordered orthopedic devices, including wrist splints and an Ace wrap for a painful knee. One resident with a left hand fracture had an MD order for a left hand splint to be worn at all times, but was twice observed in bed without it, and his care plan did not address this splint. Another resident with CHF, morbid obesity, COPD, and arthritis pain had an order for a daytime Ace wrap to the right knee, yet was observed without it and had no related care plan interventions. A third resident with a left hand contracture and multiple fractures had an order for a left wrist splint to be worn at all times, but was observed in bed without the splint despite a care plan noting a splint in place. The interim DON, MDs, and Administrator confirmed that these devices were ordered for pain control and to prevent worsening contractures, and that staff were responsible for ensuring orders were followed and refusals or issues were communicated.
The facility failed to provide adequate supervision and accident prevention for two cognitively impaired residents identified as elopement risks. One resident with multiple medical conditions and moderate cognitive impairment was able to observe or obtain the front door code, walked unaccompanied through the lobby, and exited the coded front door without staff awareness, later being found offsite and transported to the ER in an altered mental status. Another resident with hemiplegia, dysphagia, contractures, and moderate cognitive impairment, whose care plan required close monitoring and a functioning Wander Guard, was observed sitting alone and unsupervised on the front patio. The ADM acknowledged that the master door code had not been changed for an extended period, that a high-risk resident knew the code and could override the Wander Guard system, that most Wander Guard devices were visual only and non-alarming, and that there was no policy addressing high elopement-risk residents’ knowledge of the master door code, resulting in a deficiency under F689 for accidents and supervision.
Two residents with significant cognitive and psychiatric conditions were discharged without documented discharge planning, clear identification of the receiving provider, or complete clinical transfer information. Care plans lacked discharge planning, discharge instruction forms were left blank, and transfer reports omitted key data such as behavior, ambulation, continence, and feeding status, as well as the actual facility name. Although physician orders allowed transfer "to another facility," the residents were instead released into the care of a non-profit placement agency that first took them to a hospital for evaluation and then sought group home placements, while RPs were not clearly informed of the discharge destination at the time of transfer. The DON, ADM, and BOM gave inconsistent accounts of the type of setting involved, there was no documented IDT discharge meeting, and the facility’s own discharge planning policy requirements for involving the resident/RP and identifying a specific, appropriate discharge destination were not followed.
Three residents with cognitive and physical impairments did not have access to a working and reachable call light system, as observed during surveyor rounds. One resident's call light was found on the floor, another's was hanging out of reach above the bed, and a third, who was blind, could not locate her call light, which was found in a closed drawer. Staff interviews confirmed the importance of call light accessibility, and facility policy required call lights to be within reach, but these requirements were not met.
Surveyors found expired and potentially moldy food items in the kitchen's walk-in refrigerator, with unclear or missing labeling and exposed food in the freezer. Staff interviews revealed inconsistent food rotation and cleaning practices, and a cockroach was observed in the refrigerator. The facility lacked a clear pest control policy and specific procedures for handling expired foods, leading to unsanitary conditions.
Three residents had inaccurate MDS assessments, with two not reflecting active pressure ulcers and one incorrectly marked as receiving dialysis. Documentation in care plans, physician consults, and orders confirmed the presence or absence of these conditions, but the MDS did not match. Staff interviews revealed the errors were due to human error and lack of communication, and the facility did not have a specific policy beyond following the CMS RAI Manual.
A resident requiring assistance with ADLs, including bathing, did not receive scheduled showers as documented in her care plan, with only three showers recorded for the month and no refusals noted. Despite staff expectations and facility policy requiring showers three times weekly and proper documentation, the resident reported missed showers and staff interviews confirmed lapses in both care provision and documentation.
A resident with severe cognitive impairment and multiple chronic conditions, who was on hospice and designated as full code, was found unresponsive. The LVN on duty did not initiate CPR, mistakenly assuming the resident was DNR due to hospice status, despite clear documentation of full code status. Facility staff failed to verify and act on the resident's code status, resulting in no basic life support being provided prior to EMS arrival.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A CNA placed two incontinence briefs on a resident with severe dementia and chronic kidney disease, despite facility policy and staff training prohibiting this practice. The CNA stated the resident was combative and the second brief was used to manage heavy incontinence and reduce care struggles. Other staff confirmed that double briefing is not allowed and is addressed in regular training. The incident was reported by a family member, and facility records showed the resident required assistance with toileting and had a history of UTIs.
A resident with dementia, anxiety, and hypothyroidism was not provided with a comprehensive care plan reflecting her current UTI, history of UTIs, severe sepsis, E. coli bacteremia, and COVID-19. Despite having physician orders for antibiotics and cranberry capsules, these were not included in the care plan or MDS. The DON and administrator acknowledged the oversight, and the facility's policy requires care plans to be updated and used to guide care, but this was not followed.
Several residents with diabetes did not receive or have documented administration of prescribed insulin and blood glucose checks over multiple months. MAR reviews showed blank entries for insulin administration and blood sugar monitoring, with staff unable to provide clear explanations for the omissions. Residents generally believed they received their medications as scheduled, and staff interviews referenced possible electronic record issues, but documentation gaps persisted beyond that period.
A resident with multiple complex medical conditions and moderate cognitive impairment experienced a four-hour delay in receiving peri care after incontinence, despite multiple requests for assistance. The delay was caused by a staffing shortage when one CNA called in sick and no replacement was available, leaving the remaining CNA unable to meet all residents' needs in a timely manner.
A CNA did not perform hand hygiene or change gloves appropriately while providing perineal care to a resident with multiple medical conditions and impaired cognition. The CNA handled both clean and soiled items with the same gloves, contaminated supplies, and failed to wash hands before and after care, contrary to facility policy.
A resident with multiple complex medical conditions, including an ostomy and functional quadriplegia, regularly emptied his own colostomy bag and discarded waste on the floor, creating an infection control issue. Although staff were aware of this behavior and discussed it in meetings, the care plan did not include measurable objectives or interventions to address the resident's self-management of the colostomy, resulting in a lack of individualized care planning.
A resident with significant physical disabilities and dependence on dialysis did not receive adequate bathing assistance, receiving only a few showers or baths over a two-month period. Staff interviews revealed missed documentation, inconsistent care, and scheduling conflicts, leading to a lack of personal hygiene services as required by the care plan.
The facility failed to provide scheduled showers to three residents, impacting their hygiene and well-being. A resident with multiple health issues did not receive any showers over a month, while two others received only two showers instead of the scheduled three per week. Staff interviews revealed issues with documentation, staffing, and oversight of shower schedules.
A facility failed to provide adequate pharmaceutical services for three residents, as evidenced by blank areas in their medication administration records (MARs). The absence of a monitoring system and medication error reports contributed to this deficiency. Interviews with staff revealed a lack of awareness and use of medication error reporting, and the facility's ADM acknowledged gaps in nursing leadership and the absence of a system to monitor medication administration.
A resident with asthma did not receive her prescribed ipratropium-albuterol solution for several months due to a failure in medication management. Despite having a care plan that included nebulizer treatments, the facility's records showed inconsistencies and omissions in administering the medication. Interviews revealed a lack of communication and awareness of the pulmonologist's orders, leading to the resident missing essential treatments.
The facility failed to securely store medications, as observed when a closet near the medication room was found ajar with containers of liquid polyethylene glycol inside. The LVN on duty was unaware of the closet's contents and lacked a key to lock it. The facility administrator confirmed that all medications should be stored in locked areas, but was unaware of the laxative's presence in the closet.
The facility failed to manage and maintain a system for accounting resident trust funds, affecting a resident and the facility as a whole. Due to a change of ownership, the accounts were frozen, and the facility lacked access from early January to late February. This resulted in the inability to provide trust fund statements or access funds for residents, impacting their ability to meet personal needs. The facility's policy on resident rights, which includes managing personal funds, was not upheld.
A resident did not have her prescribed medications, Depakote and Potassium, documented as administered on multiple occasions. Interviews with staff revealed inconsistencies in medication administration and documentation practices, and facility policies did not address these procedures.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical conditions requiring such precautions. The resident, who had osteomyelitis, a stage 4 pressure ulcer, and other conditions, was transferred by a CNA without PPE. Observations showed no EBP signage or PPE supplies in the resident's room. Staff interviews revealed awareness of EBP requirements but confusion about responsibilities for posting signs. The facility's policy mandates PPE use and signage for residents with open wounds or medical devices, highlighting a lapse in infection control practices.
A resident with CHF and chronic respiratory failure was not weighed daily as ordered, and significant weight gain was not reported, indicating potential fluid overload. Additionally, lab results were delayed and not communicated to the medical provider, hindering effective management of the resident's condition. The resident experienced a decline, was hospitalized with sepsis, and subsequently died.
A resident with chronic respiratory and heart failure experienced a delay in receiving necessary lab tests due to the facility's failure to collect a blood specimen as ordered. The resident suffered from shortness of breath and altered mental status, leading to hospitalization and a diagnosis of sepsis. Interviews revealed systemic issues in lab management, including missing lab tracking and lack of communication, contributing to the deficiency.
A facility failed to promptly notify a physician of abnormal lab results for a resident with dementia and diabetes, leading to a delay in medical review. The lab results, drawn on February 20, were not reviewed by the physician until March 6 due to a lack of follow-up by the ADON and an LVN. The resident's care plan required notifying the physician of lab results, but the facility's policy was not followed, placing the resident at risk for delayed intervention.
The facility failed to ensure call lights were within reach for three residents, violating resident rights. A resident with epilepsy had his call light on the floor, out of reach, while another with moderate cognitive impairment had his call light hanging on the side of the bed. A third resident with severe cognitive impairment had his call light under the bed. Staff interviews revealed that it was expected for CNAs to ensure call lights were within reach, but this was not consistently done.
The facility failed to ensure accurate MDS assessments for three residents, leading to potential errors in care. A resident with epilepsy and seizures, another with heart and kidney issues, and a third with Down syndrome and respiratory failure had assessments that did not reflect their self-care needs, despite care plans indicating deficits. The new MDS Coordinator recognized the importance of accurate assessments for achieving residents' goals.
The facility failed to provide full visual privacy in dual occupancy rooms, affecting residents' dignity and privacy during care. Observations showed that privacy curtains did not fully enclose the beds, exposing residents to passersby when doors were opened. A resident expressed concerns about being exposed during care, and the facility's DON and Administrator acknowledged the issue.
The facility did not report a gas leak incident to the State Survey Agency within the required 24-hour period. A gas leak in the kitchen led to the evacuation of all residents, who were outside for about 30 minutes before being cleared to return. The administrator did not report the incident due to a lack of guidance from the corporate office. Despite the potential risk, no residents were adversely affected.
A facility failed to complete accurate PASARR Level I screenings, resulting in a deficiency for a resident with bipolar disorder and epilepsy. The resident's PASARR did not reflect their mental illness or IDD, despite being on antipsychotic medication and having impaired cognitive function. The Regional MDS coordinator acknowledged the oversight, noting the PASARR was not verified upon admission, contrary to facility policy.
The facility did not comply with food safety standards as the DM and DA failed to wear proper hair and beard restraints while preparing food. Observations showed the DM's hair was not fully covered, and the DA did not wear a beard net. Interviews revealed a lack of awareness and compliance with the facility's sanitation policy, which mandates hair and beard restraints to prevent food contamination.
The facility failed to provide necessary pharmaceutical services, resulting in missed medication doses for two residents. One resident with Parkinson's disease missed three doses of carbidopa-levodopa due to a failure in reordering, leading to increased tremors. Another resident with chronic pain missed several doses of pregabalin due to miscommunication about a new prescription, and was unable to receive diphenhydramine as it was out of stock. The DON identified a lack of a systematic approach to medication reordering as the cause.
A privacy breach occurred when staff at an LTC facility took and posted photos during a CNA week celebration, inadvertently exposing two residents' personal and medical information. A resident's credit card details and another's medical information were visible in the background of photos posted on Facebook. Staff interviews indicated awareness of HIPAA regulations, but the incident happened due to a last-minute decision to use the conference room. No grievances were filed regarding this breach.
Failure to Care Plan Ongoing Medication Refusals for a Cognitively Impaired Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s repeated refusal of medications. The resident was a 70-year-old male admitted with acute kidney failure, pain in the left hand, and traumatic brain compression with herniation. His MDS comprehensive assessment showed a Cognitive Patterns score of 6, indicating severe cognitive issues. The existing care plan included a focus on impaired cognitive function with an intervention to administer medications as ordered and monitor for side effects and effectiveness, and a separate focus on the resident’s preference to receive one pill with a full container of pudding. However, there was no specific care plan focus or interventions addressing his ongoing refusal to take multiple prescribed medications. Record review of the MARs for February and March showed that the resident refused numerous medications on multiple occasions, including fluticasone nasal spray, Lidoderm patches, sodium chloride nasal solution, atorvastatin, melatonin, Seroquel, apixaban, gabapentin, lamotrigine, levetiracetam, and sevelamer carbonate. Despite this pattern of refusals, the care plan was not updated to include measurable objectives, timeframes, or individualized interventions to address the refusals. The resident reported that he did not take medications he disliked because they made him feel sick and tasted terrible, and he believed he would get better on his own. He stated that his pain was there for a reason and that medications covered up the pain when there were severe problems. Multiple staff interviews confirmed that medication refusals were not incorporated into the resident’s care plan. LVN A stated that medication refusals should be in the care plan and that she documented refusals in progress notes or the MAR but had not been asked to review care plans and had not done so. The interim part-time DON, who assisted with care plans, stated that medication refusal should be care planned and that everything a resident did had to go in the care plan, but acknowledged difficulties with documentation due to heavy reliance on agency staff. RN A, identified as responsible for care plans, stated that medication refusals should be care planned and that she relied on 24-hour reports and nurses’ input, but she was unsure if this resident refused medications and believed he would take them with pudding. Other nurses and aides reported hearing or observing the resident refuse medications, sometimes even when pudding was offered, and stated that such refusals should be care planned with interventions. The Administrator described the care plan as a blueprint of who the resident was and agreed that medication refusals should be care planned with interventions, but the resident’s care plan still lacked a specific problem and interventions for his repeated medication refusals, despite the facility’s written policy that care plans be used to guide daily care and be updated when changes in condition occur. The facility’s care plan policy, “Using the Care Plan,” stated that completed care plans are to be used in developing residents’ daily care routines, must be available to staff responsible for providing care, and that changes in residents’ conditions must be reported so that assessments and care plans can be reviewed and updated. It also required that documentation be consistent with the resident’s care plan. In this case, although staff documented refusals on the MAR and were aware of the resident’s behavior and preferences regarding medication administration, this information was not translated into a comprehensive, person-centered care plan with measurable goals and interventions specifically addressing the ongoing medication refusals, leading to the cited deficiency. The physician reported he did not remember being informed that the resident was refusing medications and stated that if a resident repeatedly refused medications, he would want to know and that the facility should care plan such refusals. Agency nurses reported limited familiarity with the resident and inconsistent use or review of care plans. Overall, the deficiency arose from the facility’s failure to integrate known, ongoing medication refusals into the resident’s care plan, despite multiple staff recognizing that such refusals should be care planned and despite a facility policy requiring care plans to reflect changes in condition and guide care and documentation.
Failure to Provide Necessary Nail and Skin Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically nail and skin care, to residents who were unable to perform this care independently. For one resident with acute kidney failure, traumatic brain compression with herniation, blindness, and severe cognitive impairment, surveyors observed extremely thick, yellow-brown, distorted toenails extending past the tips of the toes, with brittle, curved nails growing away from the nail bed. The same resident’s feet had extremely dry, flaking, rough skin with thickened areas and discolored patches, as well as small red scabs on a toe. His fingernails extended approximately three-quarters of an inch past the fingertips with visible brown and black debris that appeared to be dirt. Despite these conditions, shower sheets for this resident documented that there was no dryness, abnormal color, abnormal skin, hardened skin, and that toenails did not need to be cut, and these assessments were signed by charge nurses. Another resident, with chronic diastolic heart failure, morbid obesity, chronic kidney disease, and severe cognitive impairment, was also found with extremely thick, yellow-brown, elongated, brittle, curved, and distorted toenails on both feet, with nails growing outward away from the nail bed. His feet and lower legs had extremely dry, flaking skin with thick layers extending up to the shins, resembling fish scales and appearing as if the skin was cracking. His fingernails were approximately three-quarters of an inch past the fingertips, jagged and brittle, with dark brown material inside the nails that appeared to be dirt. Podiatry records documented nail dystrophy, nail thickening, elongated and discolored toenails, and thickened dystrophic nails with subungual debris on both feet, with a plan for follow-up in two months. However, multiple shower sheets for this resident also indicated no dryness, abnormal color, abnormal skin, hardened skin, and that toenails did not need to be cut, and were signed by charge nurses. A third resident, with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left dominant side and contractures of the left shoulder and elbow, had a care plan identifying an ADL self-care performance deficit requiring extensive assistance with personal hygiene and oral care. Observations showed this resident’s toenails extended past the tips of the toes, with big toenails about one-quarter inch past the tips and other toenails overly long and curved either toward the big toe or upward away from the nail bed. His fingernails were overly long, extended past the fingertips, jagged and uneven, and yellow in color. Two residents reported that their long fingernails bothered them; one stated his nails looked like fangs, were very dirty underneath, and that he wanted them clipped, and another stated his nails were too long, caught on his clothes, and poked him in the face, and that staff did not want to cut his nails. Multiple staff interviews confirmed that the residents’ nails were excessively long, dirty, and in poor condition, that these conditions were not documented or communicated as required, and that expectations for CNAs and nurses to assess, document, and trim nails or refer to podiatry were not followed, resulting in residents not receiving needed ADL care for grooming and hygiene. Interviews with nursing staff and leadership further described inconsistent understanding and implementation of responsibilities for nail care. An LVN, when shown photos of one resident’s nails, acknowledged they should have been cut, described the feet as very dry and scaly, and stated that such conditions should be documented on a skin assessment. Another LVN, an agency nurse, reported having seen very long finger and toenails on a resident during a skin assessment but did not chart this, did not discuss nail care with the resident, and did not recall informing anyone, despite acknowledging that the facility’s expectation was to document, perform, or pass along the need for nail trimming. Another LVN stated she had been told nurses do not cut toenails and believed only the podiatrist did so, and that she had never been told she needed to cut resident toenails, only fingernails. In contrast, the Administrator stated that CNAs were expected to identify nail care needs and notify nurses, that nurses were expected to clip both finger and toenails, and that relying solely on the podiatrist for toenail trimming was not acceptable. The interim DON, upon viewing photos of residents’ nails and feet, stated she had not been aware of their condition, described the nails as dirty and the situation as unacceptable from an infection control and dignity standpoint, and indicated that head-to-toe skin assessments were expected to include feet and nails. These observations and interviews demonstrate that residents who were unable to perform ADLs did not receive necessary services to maintain grooming and personal hygiene, specifically clean and properly trimmed fingernails and toenails, despite facility policies stating that residents unable to carry out ADLs independently would receive appropriate care and services to maintain hygiene. The facility’s own ADL policy stated that residents unable to carry out ADLs independently would be provided with care, treatment, and services to maintain or improve their ability to perform ADLs, including appropriate support and assistance with hygiene such as bathing, dressing, and grooming. A skin integrity policy stated the purpose was to ensure residents did not develop pressure ulcers or injuries unless clinically unavoidable and that the facility would provide care and services consistent with professional standards of practice. However, the documented shower assessments that repeatedly indicated no dryness, abnormal skin, or need for toenail trimming, in contrast with the observed conditions of thick, elongated, discolored, and dirty nails and severely dry, scaly skin, show that these policies were not followed in practice for the residents reviewed. The combination of inaccurate or incomplete documentation, failure to act on observed nail and skin conditions, and inconsistent understanding among staff about who was responsible for nail care led to residents not receiving necessary ADL assistance for grooming and personal hygiene.
Failure to Ensure Ordered Orthopedic Devices and ROM Supports Were Used as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with limited range of motion received prescribed orthopedic devices and related services to maintain or improve function. For one male resident with severe cognitive impairment and a history of traumatic brain compression and left hand pain, the MD ordered a left hand splint to be worn at all times. Surveyors observed this resident in bed on two occasions without the left hand splint in place, once with the splint found on the dresser. His care plan addressed risk for skin breakdown and a right hand splint, but contained no care plan focus or interventions for the ordered left hand splint. Another male resident with severe cognitive issues, chronic diastolic CHF, morbid obesity, and COPD had an MD order to wrap his right knee with an Ace bandage during the day and remove it at bedtime for arthritis pain. His care plan addressed potential for pain and risk for injury from decreased ADLs, but did not include the Ace bandage order or related interventions. During observation, this resident was found in bed without the Ace bandage on his right knee, despite the standing order. The ordering MD later clarified that the Ace bandage was to be applied as needed and emphasized the importance of following orders or notifying him if there were issues. A younger female resident with bipolar disorder, fractures of the right femur and right humerus, and a left hand contracture had an MD order for a left wrist splint to be worn at all times. Her care plan documented impaired physical mobility with a left hand contracture and noted a splint in place, with an intervention to consult PT to evaluate ROM and motor movements. However, during observation she was in bed without the left wrist splint on. She reported that when she first came to the facility she had a contracture on her right hand and received therapy, and that she puts her brace on herself. The interim DON and Administrator both stated that if residents had orders for splints or an Ace bandage, they should have been wearing them, and that nurses were responsible for ensuring orders were followed and communicating refusals or issues with the MD. The facility’s failure to ensure these prescribed devices were in use as ordered, and to incorporate the orders into the residents’ care plans, was cited as placing residents at risk of impaired skin integrity, further decline, and decreased quality of life and quality of care.
Failure to Prevent Elopement and Inadequate Supervision of High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for residents at risk of elopement, resulting in one resident leaving the building unsupervised and another high-risk resident being left outside alone. One resident, a female with type II diabetes mellitus, congestive heart failure, hypertension, acute kidney failure, major depression, and schizoaffective disorder, bipolar type, had a BIMS score of 8 indicating moderate cognitive impairment. Her care plan was updated after the incident to identify her as an elopement risk/wanderer. On the day of the elopement, she was last seen by an LVN shortly after 6:00 a.m. when she refused Accu-Checks and again around 7:40 a.m. near the breakfast room. A CNA reported that she delivered the resident’s breakfast tray around 7:50 a.m. and found the resident missing when she returned around 8:40 a.m. to pick up the tray. Video footage later showed this resident walking unattended in the front living room area at 8:15 a.m. and exiting the front door at 8:16 a.m. without staff supervision. The facility’s Administrator reported that the resident exited by using the door code and stated she had no prior knowledge that the resident knew the code, speculating that the resident must have obtained it from her boyfriend, another resident. The Administrator also stated that the master door code had not been changed since 2024 and that it had not been changed due to the perceived financial cost of updating all door codes. The facility’s elopement policy required prompt search and notification procedures once a resident was found missing, but the report documents that the resident was ultimately located offsite by a security guard at a local credit union approximately 0.5 miles away after crossing a busy frontage road, and was transported by EMS to a hospital ER, where she was found in an altered mental status. A second resident, a male with hemiplegia and hemiparesis affecting the left dominant side, dysphagia, and contractures of the left shoulder and elbow, had a BIMS score of 11, also indicating moderate cognitive impairment. His care plan included a focus that he often went outside and sat at the front entrance without alerting staff of his whereabouts, and he was identified as an elopement risk/wanderer with impaired safety awareness. Interventions included monitoring his whereabouts each shift and ensuring a functioning Wander Guard device. Despite this, observation showed this high elopement-risk resident sitting outside on the patio alone and unsupervised. The Administrator acknowledged that this resident knew the door code prior to her employment, that his knowledge of the code overrode the Wander Guard system, and that most Wander Guard devices in the facility were visual only and did not alarm. The Administrator stated there was no policy addressing residents with high elopement risk having knowledge of the master door code. These actions and inactions related to door code management, Wander Guard use, and supervision of residents at risk for elopement led to the identified deficiency under F689 for accidents and supervision.
Removal Plan
- Complete elopement risk assessments for all residents to ensure ongoing evaluation and implementation of appropriate preventive interventions.
- Implement a universal reset of the master door code to reduce the risk of unauthorized exit and elopement due to Resident #1's demonstrated knowledge of the door access code.
- Complete a facility-wide in-service for the Administrator and Maintenance Director on door code security and the requirement to report any known or suspected door code breach to the Maintenance Director and/or Administrator, with signature acknowledgment.
- Implement a camera monitoring system at the nursing station to enhance supervision of residents and monitor exit activity.
- Restrict authorization to initiate and implement door code changes when codes are compromised or breached to only the Maintenance Director and Administrator.
- In-service the Director of Nursing on operation, monitoring expectations, and response procedures related to the camera monitoring system, with signature acknowledgment.
- In-service charge nurse staff and agency staff on operation, monitoring expectations, and response procedures related to the camera monitoring system prior to start of shift, with signature acknowledgment.
- Include education on camera monitoring and reporting procedures as a required component of new hire orientation and policy change.
- Include education on door code security and reporting procedures as a required component of new hire orientation.
- Contact the door system manufacturer or security system company to request and coordinate the change of all access and exit door codes.
- Maintain sole possession of the master door code and all instructions for code changes by the Maintenance Director and Administrator.
Failure to Plan and Document Safe, Destination-Specific Discharges for Two Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for two cognitively impaired residents prior to transfer/discharge, and to ensure they were discharged to a known, appropriate provider with adequate clinical information. One resident, a 74‑year‑old female with schizoaffective disorder, bipolar type, CHF, and major depressive disorder, had a BIMS score of 8 indicating moderate cognitive impairment. Her care plan, initiated in December and last revised in early January, contained no discharge planning. The other resident, an 82‑year‑old male with dementia, traumatic subdural hemorrhage, and paranoid schizophrenia, had documentation indicating he was severely cognitively impaired (BIMS summary score 99) and rarely/never understood, yet his care plan also reflected no discharge planning. For both residents, the facility’s discharge instruction forms dated the day of transfer were blank, with no information or questions completed. For both residents, the transfer/discharge reports were incomplete and inaccurate, and did not clearly identify the discharge destination or provide key clinical information. The transfer report for the first resident listed a transfer to a nursing home but did not record the name of the facility and omitted behavior, ambulation, bladder, bowel, and feeding information. The transfer report for the second resident listed a transfer to an acute care hospital, omitted a primary contact, and also lacked behavior, ambulation, bladder, bowel, and feeding information. Physician telephone orders for both residents only stated they “may transfer to another facility,” without specifying the receiving provider. Progress notes for the first resident documented that she was discharged by wheelchair van in stable condition with medications and that discharge instructions were reviewed, but there was no documentation of the actual receiving facility. The administrator later documented speaking with an emergency contact about the resident’s “location” and noted that messages had been left for the resident’s RP regarding the transfer, but there was no evidence of a completed discharge plan or clear destination. Interviews and additional record review showed that both residents were in fact discharged into the care of a non‑profit placement agency rather than directly to a known SNF or group home, and that the RPs were not clearly informed of the discharge destination at the time of transfer. The executive director of the placement agency stated she told the facility she would take both residents to a hospital for evaluation and then find placement depending on their needs, and that she informed the facility both residents were going to the hospital. She reported that one resident had a mental health episode while in her care, resulting in police involvement and transfer to a hospital for emergency mental health services, and that the other resident was moved between group homes after an initial one‑day stay. She also stated that both residents were discharged with medications, but one resident left with only the clothes he was wearing and neither resident had personal belongings. The DON and ADM gave conflicting accounts of the type of setting to which the residents were sent, with the ADM describing it as a personal care home and the DON stating she thought it was a nursing home, and both acknowledged lack of detailed knowledge about the agency. The facility’s own discharge planning policy required an IDT‑driven, documented discharge plan that identified a discharge destination meeting the resident’s health and safety needs and involved the resident and RP, but interviews with the DON, ADM, BOM, RPs, and emergency contacts showed there was no documented IDT discharge meeting for either resident, inconsistent or absent notification to RPs on the day of discharge, and no documented evaluation or communication of a specific, appropriate post‑discharge provider at the time the residents left the facility.
Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that three residents had access to a working and reachable call light system, as required for their safety and accommodation of needs. Observations revealed that one resident's call light pad was on the floor, out of reach while the resident was in bed. Another resident, who was at high risk for falls and had their bed placed on the floor, had their call light hanging over a light fixture several feet above and out of reach. A third resident, who was blind and required assistance for transfers and toileting, was unable to locate her call light, which was found tucked away in a closed nightstand drawer, inaccessible to her. Interviews with staff confirmed that these residents were able to make their needs known and required the use of their call lights for assistance, especially given their high fall risk, cognitive impairments, and physical limitations. Staff acknowledged the importance of keeping call lights within reach and stated that it was the facility's expectation for all staff to ensure this. The residents' care plans also specifically included interventions to keep call lights accessible and to encourage their use for requesting help. Record review of the facility's policy on answering call lights indicated that call lights should be plugged in, functioning, and accessible to residents at all times, including when in bed, on the toilet, in the shower, or on the floor. Despite these policies and care plan interventions, the facility did not ensure that the call lights were within reach for these residents, as directly observed and confirmed through staff and resident interviews.
Deficient Food Storage, Labeling, and Pest Control in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and pest control. During inspection, expired and potentially moldy food items were found in the walk-in refrigerator, including jars of ranch dressing, cherries, relish, pickles, and bottles of chocolate syrup, all with unclear or outdated labeling. In the walk-in freezer, opened boxes of turkey franks and hamburger patties were left exposed. Staff interviews revealed that there was no designated person responsible for cleaning and rotating food in the refrigerator and freezer, and that food rotation practices were inconsistently followed. The kitchen cook and dietary manager both stated that opened food should be labeled with open and use-by dates, but this was not consistently done, and some food items had been left unused for extended periods. Additionally, a cockroach was observed on the floor inside the walk-in refrigerator, indicating a pest control issue. The dietary manager and maintenance staff confirmed that pest control services were scheduled monthly, but the last recorded service was over a month prior to the observation. The facility was unable to provide a pest control policy when requested, and the only documentation available was a pest control log and invoices. The presence of pests in food storage areas was not addressed in the facility's undated food storage and handling policy. Record review of facility policies and state regulations showed that the facility's written procedures did not include specific guidance on handling expired foods. Staff interviews confirmed that the expectation was for all staff to participate in cleaning and rotating food, but there was no clear assignment of responsibility or consistent practice. The lack of clear procedures and oversight led to the accumulation of expired and potentially hazardous food items, as well as the presence of pests in food storage areas.
Inaccurate MDS Assessments for Pressure Ulcers and Dialysis
Penalty
Summary
The facility failed to ensure that comprehensive assessments accurately reflected the current status of three residents. For one resident, the Minimum Data Set (MDS) assessment did not indicate the presence of an active Stage 3 pressure ulcer, despite documentation in the care plan, progress notes, physician wound consults, and physician orders confirming the existence and treatment of the wound. Another resident's MDS inaccurately indicated that the resident was receiving dialysis, although there was no diagnosis, care plan focus, or physician order for dialysis, and the resident's face sheet did not list end-stage kidney disease. A third resident's MDS failed to reflect an active unstageable pressure injury, even though the care plan, physician consults, and orders documented the presence and treatment of pressure injuries to the heels. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of awareness regarding the discrepancies in the MDS assessments. The MDS Coordinator acknowledged that the MDS should be updated within 14 days after a significant change in condition, such as the development of a new pressure ulcer, and admitted that the errors were due to human error and lack of team communication. The DON and Administrator also confirmed the importance of maintaining accurate and current MDS assessments and recognized that the errors had not been identified prior to the survey. Review of the facility's documentation and the CMS Resident Assessment Instrument (RAI) Manual confirmed that significant changes, such as new pressure ulcers or errors in previous assessments, require timely updates and corrections to the MDS. The facility did not have a specific policy for MDS accuracy beyond following the CMS RAI Manual. The errors in the MDS assessments resulted in inaccurate information being available for care planning and management, as reflected in the facility's resident matrix and other records.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), including bathing, did not receive showers as scheduled. The resident, an elderly female with diagnoses including a need for personal care assistance, lack of coordination, cognitive communication deficit, major depressive disorder, and hypertension, was assessed as needing partial to moderate assistance with showers. Her care plan specified that she should receive limited to extensive assistance with bathing or showers as necessary, with a scheduled frequency of three times per week. Record reviews revealed that during the month in question, only three showers were documented for the resident, despite a schedule of showers on Mondays, Wednesdays, and Fridays. There were no documented refusals of showers, and the resident's care plan did not address any behaviors related to refusing care. Interviews with the resident confirmed that she was aware of her shower schedule but reported not receiving showers as expected and not being able to recall when her last shower occurred. She stated that when she requested a shower after a missed session, she was told she might be fit in if there was a cancellation, but this did not occur. Staff interviews indicated that showers were to be provided and documented by CNAs, with refusals also to be recorded. The DON and ADM both confirmed that the expectation was for showers to be provided and documented as scheduled, and that there were no known refusals or behaviors preventing the resident from receiving care. The facility's shower policy required documentation of showers and refusals, as well as monitoring for compliance. The lack of documentation and provision of scheduled showers for the resident constituted a failure to ensure necessary services for maintaining personal hygiene.
Failure to Provide CPR to Full Code Resident on Hospice
Penalty
Summary
A deficiency occurred when facility staff failed to provide basic life support, including CPR, to a resident who was designated as full code and required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with severe cognitive impairment, multiple chronic conditions including dementia, polyneuropathy, chronic kidney disease, and was on hospice care, was found unresponsive by staff. Despite her full code status, no life-saving measures were initiated. The resident's care plan and medical records clearly indicated her full code status, and facility policy stated that hospice enrollment does not automatically change a resident's code status. However, the LVN on duty assumed the resident was a DNR due to her hospice status and did not attempt CPR. The LVN reported relying on information from the CNA and was not familiar with the resident, as it was her first time working with her. The administrator confirmed that the LVN did not perform CPR and reiterated that CPR was expected for full code residents, regardless of hospice enrollment. Interviews with staff revealed a lack of awareness and understanding regarding code status identification and the distinction between hospice care and DNR orders. The facility's failure to verify and act according to the resident's documented code status resulted in the omission of basic life support measures. This event was identified as Immediate Jeopardy due to the failure to provide required emergency care to a resident with a full code status.
Removal Plan
- Nursing staff and agency personnel received re-education from the DON on the proper procedure for locating a resident's code status within the electronic medical record.
- All nursing staff and agency personnel will receive in-service training.
- The Chief Executive Officer in-serviced the DON on the proper procedure for locating a resident's code status within the electronic medical record.
- The DON in-serviced the ADON on locating residents code status on electronic medical record.
- A comprehensive audit of each resident's code status was completed to ensure accuracy and compliance with facility policy.
- Nursing staff and agency personnel were re-educated on emergency response procedures and initiating CPR for any Full Code resident without signs of life.
- Staff and agency personnel received education regarding the meaning of the red and green markers on each resident's door to indicate code status.
- A Performance Improvement Plan was put in place for trend analysis and system improvement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident Dignity and Adhere to Incontinence Care Policy
Penalty
Summary
A certified nursing assistant (CNA) placed two incontinence briefs on a female resident with severe dementia, chronic kidney disease stage 4, and a history of urinary tract infections. The resident required partial to moderate assistance with toileting hygiene and was always incontinent of urine and bowel. The CNA stated that the resident was combative and that the second brief was used to prevent the resident from urinating through the first brief before she could be changed again. The CNA also indicated that she believed it would be less of a struggle to change the resident later if two briefs were used. Another staff member, a hospitality aide, denied assisting with care and stated she only performed non-care tasks. Interviews with other staff, including licensed vocational nurses (LVNs) and assistant directors of nursing (ADONs), confirmed that facility policy and staff education prohibit the use of more than one brief at a time, citing risks to skin integrity and resident dignity. The ADONs and administrator stated that staff are regularly trained and checked off on peri-care and that double briefing is not allowed. However, the CNA involved admitted to the practice, and the family member of the resident reported this was not the first occurrence, expressing concern due to the resident's medical history. Facility records, including care plans and in-service training documentation, reflected that staff were instructed to maintain skin health, prevent infections, and provide care in a manner that supports resident dignity. Despite these policies and training, the incident occurred, and the resident was found with two briefs, which was not in accordance with facility policy or the resident's care plan. The resident was not able to be interviewed due to cognitive impairment, but was observed to be clean and free of odors at the time of surveyor observation.
Failure to Update Care Plan for Resident with UTI, Sepsis, and COVID-19
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The care plan did not address the resident's current urinary tract infection (UTI), history of UTIs, or recent diagnoses of severe sepsis, E. coli bacteremia, and COVID-19 following a hospital discharge. Despite the resident having physician orders for antibiotics and cranberry capsules for UTI management, these interventions and the underlying conditions were not reflected in the care plan. Additionally, the resident's Minimum Data Set (MDS) did not include her history of UTI, sepsis, COVID-19, or antibiotic use. Observations and interviews revealed that the resident was non-communicative and unable to provide information about her condition. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current UTI status and that the lack of updates could prevent nursing staff and CNAs from providing appropriate care. The DON also stated that the MDS coordinator, who is responsible for care plans, was unavailable, and that she would begin assisting with care plan updates. The administrator was unaware that the resident's UTIs were not included in the care plan and confirmed that both the MDS coordinator and DON were responsible for care plan management. The facility's policy requires that care plans be used to guide daily care routines and be updated to reflect changes in residents' conditions. Staff are expected to report changes to the nurse supervisor and MDS coordinator, and documentation must be consistent with the care plan. In this case, the failure to update the care plan with the resident's current and past medical conditions, as well as prescribed treatments, resulted in a deficiency identified by surveyors.
Failure to Administer and Document Insulin for Diabetic Residents
Penalty
Summary
The facility failed to ensure that multiple residents were free from significant medication errors, specifically regarding the administration of insulin for diabetic residents. For four out of five residents reviewed, there were documented omissions in the administration of prescribed insulins, including Glargine, Lispro, Novolog, and Lyumjev, as well as failures to perform required blood glucose checks. These omissions were identified through review of Medication Administration Records (MARs) for the months of January, February, March, and April, where blank entries indicated that medications were not administered as ordered. In several instances, there was no documentation or explanation for the missed doses, and staff interviews did not provide satisfactory clarification for the omissions. The residents involved had significant medical histories, including diagnoses of Type 2 diabetes, hypertension, obesity, muscle weakness, and other comorbidities. Their care plans included interventions such as routine insulin administration and blood glucose monitoring. Despite these documented needs, the MARs reflected multiple days where insulin and blood glucose checks were not recorded as given. Interviews with the residents revealed that they generally believed they were receiving their medications as scheduled, and none recalled missing doses or experiencing related adverse events during the review period. Staff interviews revealed inconsistent explanations for the missing documentation. Some staff cited issues with the electronic medical record system (PCC) during a change of ownership, particularly in January, which may have affected MAR documentation. However, omissions were also noted in subsequent months, and staff were unable to provide clear reasons for these gaps. The DON confirmed the presence of blank MAR entries and was unable to locate alternative proof of administration for the missing doses. Facility policy requires that all medication administrations be documented and that any omissions be explained in the resident record, which was not consistently done in these cases.
Delay in Peri Care Due to Staffing Shortage
Penalty
Summary
A deficiency occurred when a resident who was unable to perform activities of daily living did not receive timely assistance with personal hygiene and grooming. The resident, a male with multiple diagnoses including alcoholic cirrhosis of the liver, acute respiratory failure, chronic kidney disease, hypertension, dependence on renal dialysis, and syncope, had a moderately impaired cognitive status as indicated by a BIMS score of 8. On the morning in question, the resident experienced bowel and bladder incontinence at 6:30am and requested peri care multiple times using the call light. Despite repeated requests, the resident waited approximately four hours before a CNA was able to provide the necessary care. During this period, staff responded to the call light only to turn it off and inform the resident that assistance would arrive soon. The delay in care was attributed to staffing shortages, as one of the two CNAs assigned to the hallway called in sick and no replacement was available. The remaining CNA was responsible for additional residents, including one with a dialysis appointment, which further delayed response times. Facility leadership, including the DON and administrator, confirmed that the lack of a substitute CNA led to the delay in providing care. Facility policies reviewed emphasized the right of residents to be free from neglect and to receive care that maintains dignity and hygiene, which was not upheld in this instance.
Failure to Follow Infection Control Protocol During Perineal Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing perineal care to a male resident with multiple complex medical conditions, including alcoholic cirrhosis of the liver, acute respiratory failure, chronic kidney disease, hypertension, dependence on renal dialysis, and a history of syncope. The resident had moderately impaired cognition and was care planned for constipation management. During the observed care, the CNA donned gloves without performing hand hygiene, handled clean and soiled items interchangeably with the same pair of gloves, and contaminated a packet of wet wipes by touching it with soiled gloves. The CNA also failed to change gloves between handling dirty and clean items and did not perform hand hygiene after removing gloves or before leaving the resident's room. The facility's policy for perineal care requires hand hygiene before and after glove use, as well as changing gloves and performing hand hygiene after contact with soiled materials and before handling clean items. The CNA stated she had received training on peri care during orientation and believed she was following protocol, but upon review, acknowledged lapses in glove changing and hand hygiene. The Director of Nursing confirmed that the CNA did not adhere to infection control procedures as outlined in facility policy.
Failure to Develop Comprehensive Care Plan for Colostomy Self-Management
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed a resident's self-management of his colostomy bag. The resident, who had diagnoses including osteomyelitis, functional quadriplegia, and dependence on renal dialysis, was cognitively intact and had an ostomy. Despite these conditions, the care plan did not include measurable objectives or interventions related to the resident's behavior of emptying his own colostomy bag, nor did it address the associated infection control concerns. Observations and interviews revealed that the resident regularly emptied his colostomy bag himself, using a white trash bag and discarding it on the floor, which sometimes resulted in fecal matter splattering on the floor. Staff, including LVNs, CNAs, the ADON, and the DON, were aware of this behavior and acknowledged it as an infection control issue. The behavior was discussed in morning meetings, and some interventions, such as providing a tall trash can, were implemented informally, but these actions were not documented in the resident's care plan. Record reviews confirmed that the care plan focused on other aspects of the resident's care, such as gastrointestinal status and ADL deficits, but did not address the specific issue of self-emptying the colostomy bag. Staff interviews indicated that the MDS coordinator was responsible for care plans but may not have been aware of the resident's behavior, and the lack of documentation in the care plan led to a gap in individualized care planning for this resident.
Failure to Provide and Document Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for one resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. The resident, a male with diagnoses including osteomyelitis, functional quadriplegia, and dependence on renal dialysis, was found to have received only three showers or baths in March and none in April, according to the facility's shower logs. The resident reported feeling unclean and stated he had only received four bed baths in the 90 days he had been at the facility. Interviews with staff revealed inconsistencies in the documentation and provision of bathing care. Certified Nursing Assistants (CNAs) and nursing staff acknowledged that the resident often preferred bed baths and sometimes refused showers, but also admitted that refusals were not always documented as required. Staff also cited scheduling conflicts with dialysis treatments as a reason for missed showers, and there was confusion about the whereabouts of shower sheets for certain months. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that documentation should be completed for every scheduled shower, regardless of whether the resident accepted or refused, and that the lack of documentation and missed showers was a problem. The facility's policy required that residents unable to perform ADLs independently receive appropriate support and assistance with hygiene, including bathing, in accordance with their care plan. Despite this, the resident's care plan interventions for bathing were not consistently followed or documented, resulting in inadequate hygiene care over the review period.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good hygiene, nutrition, grooming, and personal and oral hygiene. Specifically, three residents did not receive showers according to their scheduled times. Resident #1, a male with chronic obstructive pulmonary disease, an amputation, major depressive disorder, diabetes, and chronic pain, did not receive any showers over a 30-day period despite being scheduled for three showers a week. He was observed with stains and dried food on his face and clothes, and his fingernails had a dark substance underneath. Resident #3, a female with diabetes, muscle weakness, morbid obesity, asthma, hypertension, and chronic pain, was dependent on two or more staff for showering. She was scheduled for showers or bed baths three times a week but only received two during the 30-day period. She reported receiving bed baths occasionally and believed there was insufficient staff to assist with her showers due to the need for a mechanical lift. Resident #7, a male with convulsions, ataxic gait, and bipolar disorder, required supervision for showering. He was also scheduled for showers three times a week but only received two. He was observed with disheveled, oily hair and stained clothing. Interviews with staff revealed issues with documentation and staffing. CNA A, an agency worker, was unaware of the shower schedule and provided bed baths when possible. RN B stated that nurses did not check if showers were completed, relying on CNAs to report any skin issues. CNAs C and D mentioned problems with the documentation system and staffing shortages, which affected their ability to provide showers. The ADON acknowledged the lack of oversight and documentation for showers, and the ADM was in the process of assigning someone to monitor the shower schedule. The facility owner stated that showers should be given as scheduled, but no policy or admission packet regarding hygiene was provided during the survey.
Medication Administration Deficiency Due to Inadequate Monitoring
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents, as evidenced by multiple blank areas in their medication administration records (MARs). This deficiency was identified during interviews and record reviews, which revealed that the facility did not have a system in place to monitor medication administration or address medication errors. The absence of documentation in the MARs suggests that medications may not have been administered as prescribed, potentially placing residents at risk of missed doses and subsequent health deterioration. Resident #1, a male with multiple diagnoses including chronic obstructive pulmonary disease, diabetes, and seizures, had several instances of blank initials in his February 2025 MAR, indicating that medications for hypertension, depression, diabetes, and other conditions may not have been administered. Despite this, Resident #1 reported no concerns about his medication regimen. Similarly, Resident #3, a female with diabetes, hypertension, and asthma, also had blank areas in her MAR, and she reported occasional missed medications due to computer issues or new staff. Resident #7, a male with a history of seizures and falls, had blank spaces in his MAR for medications related to GERD, seizures, and hyponatremia. Interviews with facility staff, including LVNs and the ADON, revealed a lack of awareness and use of medication error reports. The ADON acknowledged the absence of monitoring for MAR issues and the need for training on medication error reporting. The facility's ADM admitted to gaps in nursing leadership and the lack of a system to monitor medication administration, which contributed to the deficiency. The facility's policy on medication management emphasized the importance of communication and reporting systems for pharmaceutical service issues, which were not effectively implemented.
Failure to Administer Prescribed Asthma Medication
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who did not receive her prescribed medication for asthma. The resident, a female with a history of asthma, diabetes mellitus II, muscle weakness, morbid obesity, hypertension, and chronic pain, was supposed to receive ipratropium-albuterol solution as part of her treatment plan. However, from November 13, 2024, through February 13, 2025, she did not receive the scheduled doses of this medication. The resident's care plan included interventions for asthma, such as administering nebulizer treatments and oxygen therapy as ordered. Despite this, the facility's records, including the Medication Administration Records (MARs) and Physician Order Summary, showed inconsistencies and omissions in administering the medication. The MARs for November 2024 through January 2025 lacked the name of the medication and were blank, indicating the medication was not given. It was only in February 2025 that a new order was added, but the resident had already missed several months of treatment. Interviews with the resident, her family member, and the facility's medical doctor revealed a lack of communication and awareness regarding the pulmonologist's orders. The family member expressed concern upon realizing the resident had not been receiving her treatments, and the resident herself was relieved when the nebulizer treatments were resumed. The facility's medical doctor was unaware of the pulmonologist's visit and orders, and it was unclear if he had discontinued the nebulizer treatment. This oversight in medication management could have placed the resident at risk of health complications.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to currently accepted professional principles. During an observation, it was found that a closet adjacent to the medication room was left ajar, containing four large containers of liquid polyethylene glycol, a laxative. This closet was not secured, and the Licensed Vocational Nurse (LVN) on duty was unaware of its contents and did not possess a key to lock it. The LVN admitted that the closet was always left unlocked, and a personal bag was found leaning against the medication. The facility administrator confirmed that all medications, whether over-the-counter or prescribed, should be stored in the medication room or on a cart in a locked area. However, she was unaware of the polyethylene glycol being stored in the closet and did not know who placed it there. Upon discovery, the medication was moved to a secure location. The Texas Health and Human Services guidelines provided by the facility emphasize the importance of maintaining medication rooms, carts, and boxes as locked and secured, which was not adhered to in this instance.
Facility Fails to Manage Resident Trust Funds
Penalty
Summary
The facility failed to manage and maintain a system that ensures a full, complete, and separate accounting of each resident's personal funds entrusted to the facility. This deficiency was identified for one resident and the facility as a whole, as they did not have access to the trust fund accounts from January 1, 2025, and still lacked access by February 19, 2025. The facility was unable to provide a trust fund statement upon request for a resident on February 18, 2025. This situation arose due to a change of ownership, which resulted in the accounts being frozen, and the facility's inability to access the accounts. The Business Office Manager (BOM) and the Administrator (ADM) confirmed that they were aware of the issue, and the facility's attorneys were involved, but the problem remained unresolved. The lack of access to the trust fund accounts meant that the facility could not provide residents with their funds, affecting their ability to meet personal needs. The ADM stated that although they could see the balance in the accounts as of January 1, 2025, they lost access to the accounts in late January, leaving them unable to deposit checks or complete Medicaid applications. The Assistant Business Office Manager (ABOM) confirmed that the accounts were closed, and the former owner sent out statements on January 31, 2025. The facility's policy on resident rights, revised in December 2016, guarantees residents the right to access personal and medical records and manage their personal funds, which was not upheld in this instance.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, as evidenced by the lack of documentation for the administration of prescribed medications. The resident, a female with a history of transient cerebral ischemic attack, dementia, diabetes, and hypertension, was not documented as having received her physician-ordered medications, Depakote and Potassium, on four separate occasions in February 2025. The Medication Administration Record (MAR) for these dates showed blanks, with no signatures or initials to confirm administration, and the progress notes did not indicate whether the medications were given. Interviews with facility staff revealed inconsistencies in medication administration and documentation practices. A CNA/MA stated that medications were documented when given and that refusals were reported to the nurse. An LVN mentioned being unaware of the blanks on the MAR and noted that the resident sometimes refused medications. The ADON and ADM both expressed expectations that medications be administered and documented correctly, with the ADM emphasizing the importance of notifying the doctor if a medication was not given. Despite these expectations, the facility's policies did not address the specific procedures for administering or documenting medications.
Inadequate Infection Control Practices for Resident with Medical Devices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for a resident with multiple medical conditions requiring such precautions. The resident, a male with osteomyelitis, dependence on renal dialysis, a stage 4 pressure ulcer, and diabetes, was observed being transferred to a wheelchair by a CNA without the use of personal protective equipment (PPE). The CNA, who was responsible for transporting the resident to his dialysis appointment, stated that she did not wear PPE because she believed the resident was not on EBP, despite having been trained on PPE usage. Further observations revealed that there was no EBP signage in the resident's room, nor were there supplies of clean PPE or discarded PPE in the trashcan. Interviews with staff, including a CNA/MA and the ADON, indicated that they were aware of the requirements for EBP for residents with catheters, tubes, or other invasive devices. However, there was confusion about the responsibility for posting EBP signs, as the ADON had only recently started in her position and was awaiting clarification of duties in a meeting that had not yet occurred. The facility's policy on Enhanced Barrier Precautions, effective since April 2024, requires team members to wear gowns and gloves during high-contact care activities with residents who have open wounds or indwelling medical devices. The policy also mandates the placement of EBP signage and the availability of PPE in resident rooms. The failure to implement these precautions for the resident in question represents a significant lapse in infection control practices, potentially placing residents at risk for infection and cross-contamination.
Failure to Monitor CHF Resident Leads to Hospitalization and Death
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident with a diagnosis of congestive heart failure (CHF) and chronic respiratory failure with hypoxia. The facility did not obtain daily weights as ordered by the medical provider, which was crucial for monitoring potential fluid overload in the resident. Despite the medical provider's order to notify them of any significant weight gain, the facility did not report a weight increase of over 8 pounds within a short period, which could have indicated fluid retention. Additionally, the facility failed to timely and accurately obtain and report laboratory results as ordered by the medical provider. The resident's lab work, which included critical tests such as CBC, CMP, and others, was delayed by 20 days, and the results were not communicated to the medical provider or the resident's family. This lack of timely lab results hindered the ability to monitor and manage the resident's chronic conditions effectively, potentially contributing to the resident's decline. The resident experienced shortness of breath and altered mental status while at the facility, leading to an emergency transfer to the hospital, where they were diagnosed with sepsis and subsequently passed away. Interviews with facility staff and medical providers revealed a lack of adherence to the facility's policies on weight and lab management, contributing to the resident's deterioration and eventual death.
Removal Plan
- DON/ADON in-serviced administrative staff and nursing staff regarding policy and procedures for weight tracking and management and methods for obtaining weights.
- The resident's height and weight will be obtained upon admission, documented by nursing staff in electronic medical records and lab binder.
- The resident is then weighed at least weekly.
- Nursing staff will notify Physician, resident, and family of the weight loss/gain and documented in EMR.
- Nursing staff will monitor residents' eating habits and documented in residents EMR.
- Weekly weights will be obtained and documented by nursing staff in EMR.
- Initiation of the Weight Surveillance Form until all resident's weight has stabilized.
- Any planned weight loss will be care planned and noted in the clinical record.
- Dietitian recommendations will be implemented or if needed, sent to the physician immediately upon receipt.
- A call will be placed to the physician's office if the physician has not responded.
- DON/ADON completed a lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed.
- DON/designee will monitor and track residents' weight loss of 5% or greater with immediate notification sent to dieticians and physicians for recommendations and documented in EMR.
- DON/ADON will maintain a current list of residents and a communication form will be provided to the dietary manager to notify them of extra assistance, encouragement, substitute meals, or supplements or any weight loss identified.
- The dietary manager will document in residents' EMR followed by a consultation call to Registered dietician for further instructions.
- DON/ADON will in-service administrative staff, dietary management and staff regarding procedure with communication slips concerning weight loss, diet changes, new admits and readmits with documentation placed in residents EMR.
- The Medical Director immediately made aware of IJ for noncompliance via telephone.
- DON/ADON completed a lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed.
- Report all lab results to MD/NP immediately, report abnormal lab results to MD/NP/DON or designee and documented in each resident EMR.
- Lab tracking binder will be located at each Nurse's station.
- DON/ADON will perform lab audits to ensure all labs that are ordered are placed in the lab tracking binder.
- Proof of notification to be included on the lab report sheet via signature, route of notification and documented in the nurse's notes.
- Lab draws that cannot be drawn will be communicated to the physician immediately, documented in residents EMR and checked by DON/ADON for completion of results.
- Lab results will be maintained in the resident's clinical record via Electric Medical Record integration documentation system.
- Administrator/DON and ADON will in-service charge nurses on laboratory monitoring and management with signature for comprehension.
- Agency and PRN staff will be in-serviced prior to the start of shift in addition to the binder placed at nurses' station with lab policy and procedures.
- The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician.
- The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner.
- If issues are identified with the lab provider process, DON is to contact lab company immediately for corrective action.
- The Administrator will check lab tracking books via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process.
- QA plan to be developed by Administrator /DON to prevent recurrence of identified issues(s).
Failure to Obtain Timely Lab Services Leads to Resident Harm
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident, leading to a significant delay in medical intervention. The resident, an elderly male with chronic respiratory failure and heart failure, had a physician's order for several lab tests, including a CBC and CMP, on a specific date. However, the facility did not collect the blood specimen until 20 days later, and the CMP test was not performed. During this period, the resident experienced shortness of breath and altered mental status, eventually requiring emergency medical services and hospitalization, where he was diagnosed with sepsis. Interviews and record reviews revealed systemic issues within the facility's lab management process. The PA and MD expressed concerns about the lack of lab results, which hindered their ability to monitor and manage the resident's chronic conditions effectively. The facility's staff, including the DON and ADM, were aware of the missing lab results but failed to implement a reliable system for tracking and communicating lab orders and results. The absence of a lab tracking system and the lack of follow-up on lab orders contributed to the delay in obtaining necessary medical information. The facility's policy required timely lab services and communication of results to the attending physician, but these procedures were not followed. Interviews with staff indicated that the lab tracking book was missing, and there was no system in place to ensure labs were drawn and results communicated. The ADM acknowledged the lack of organization and accountability within the facility, which led to the deficiency and placed residents at risk of harm.
Removal Plan
- DON/ADON completed a lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed.
- Report all lab results to MD/NP immediately, report abnormal lab results to MD/NP/DON or designee and documented in each resident EMR.
- Lab tracking binder will be located at each Nurse's station.
- DON/ADON will perform lab audits to ensure all labs that are ordered are placed in the lab tracking binder.
- Proof of notification to be included on the lab report sheet via signature, date, time and route of notification and documented in the nurse's notes.
- Lab draws that cannot be drawn that day will be communicated to the physician immediately, documented in residents EMR and checked daily by DON/ADON for completion of results.
- Lab results will be maintained in the resident's clinical record via Electric Medical Record integration documentation system.
- Administrator/DON and ADON will in-service charge nurses on laboratory monitoring and management with signature for comprehension. Agency and PRN staff will be in-serviced prior to the start of shift in addition to the binder placed at nurses' station with lab policy and procedures.
- The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician.
- The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner.
- If issues are identified with the lab provider process, DON is to contact lab company immediately for corrective action.
- The Administrator will check lab tracking books monthly via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process.
- QA plan to be developed by Administrator /DON to prevent recurrence of identified issues(s).
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of abnormal laboratory results for a resident, which included hematocrit, glucose, and albumin levels that were outside the clinical reference ranges. These results were drawn on February 20, 2025, but were not reviewed by the resident's physician until March 6, 2025. The delay in communication was due to a lack of follow-up by the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) A, who were responsible for ensuring the physician received the lab results. The ADON signed the lab results as received on the day they were drawn but did not follow up until March 3, 2025, when it was discovered that the results had not been communicated to the physician. The resident involved had a medical history of dementia, diabetes mellitus type 2, and a cerebral vascular accident, with a moderate cognitive impairment as indicated by a BIMS score of 10. The resident's care plan included monitoring for anemia and diabetes, with specific interventions to notify the physician of lab results. Despite these interventions, the facility's policy for lab monitoring was not followed, leading to a delay in the physician's review of the lab results. This deficiency placed the resident at risk for delayed medical intervention.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents, which is a violation of resident rights. Resident #1, a cognitively intact male with epilepsy and recurrent seizures, was observed with his call light on the floor under the bed, out of reach. He reported that the call light was always on the floor and staff did not ensure it was within reach when they assisted him. Resident #2, a male with moderate cognitive impairment due to congestive heart failure, chronic kidney disease, and anxiety, had his call light hanging on the side of the bed, not within reach. He also stated that his call light was always out of reach, and he would wait for staff to enter the room to communicate his needs. Resident #3, a severely cognitively impaired male with Down syndrome, kidney failure, and respiratory failure, had his call light under the bed at the foot, out of reach. He was unable to communicate how long it had been there or when staff last assisted him. Interviews with staff, including CNAs and the ADON, revealed that it was expected for CNAs to make rounds every two hours or as needed and ensure call lights were within reach. The ADON and ADM both stated that it was everyone's responsibility to ensure call lights were always within reach so residents could notify staff if they needed assistance. The facility's policy on call light use emphasized the importance of positioning the call light conveniently for the resident and ensuring the call system was in proper working order. However, the observations and interviews indicated that these procedures were not consistently followed, leading to the deficiency.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments of functional abilities for three residents, which could lead to errors in care and treatment. Resident #1, a male with epilepsy and recurrent seizures, had a Quarterly MDS assessment that did not specify the type of assistance needed for self-care, despite a care plan indicating deficits in ADL self-care performance related to disease processes. Similarly, Resident #2, a male with congestive heart failure, chronic kidney disease, and anxiety, had a Quarterly MDS assessment that lacked details on self-care assistance, although his care plan noted a need for assistance with ADLs due to disease-related intolerance. Resident #3, a male with Down syndrome, kidney failure, and respiratory failure, also had an Admission MDS assessment that did not reflect the necessary self-care assistance, despite a care plan highlighting deficits in ADL self-care performance due to his conditions. The MDS Coordinator, who started after these assessments were completed, acknowledged the oversight and the importance of accurate MDS completion for meeting residents' goals. The facility's Resident Assessment Instrument Process emphasizes the need for comprehensive, individualized care plans to address each resident's medical, nursing, mental, and psychosocial needs.
Inadequate Privacy Measures in Dual Occupancy Rooms
Penalty
Summary
The facility failed to ensure full visual privacy for residents in dual occupancy rooms, specifically in rooms 100-117. Observations revealed that these rooms had a single ceiling-to-floor curtain dividing the center of the room, which stopped approximately four feet from the opposite wall, failing to provide total visual privacy. Additionally, there was no privacy curtain installed at the foot of the beds or near the doors, which could expose residents to passersby when the door is opened. This deficiency was particularly noted in the case of a resident who expressed concerns about being exposed during care procedures due to the lack of adequate privacy curtains. The resident, a cognitively intact male with a history of nontraumatic intracerebral hemorrhage and Type 2 Diabetes Mellitus, required substantial to maximal assistance with activities of daily living. During an observation, the Director of Nursing (DON) entered the resident's room to provide care, leaving the door partly open, which exposed the resident to the hallway. The resident expressed discomfort and suggested that the privacy curtain should extend around the bed to create a fully enclosed area. Interviews with the DON and the Administrator acknowledged the issue, with the Administrator noting that the lack of privacy could lead to dignity issues or embarrassment for the residents.
Failure to Report Gas Leak Incident
Penalty
Summary
The facility failed to report a gas leak incident to the State Survey Agency within the required 24-hour timeframe. On 08/22/2024, a gas leak occurred in the kitchen, prompting the evacuation of all residents. The fire department responded to the incident, confirmed the leak's origin in the kitchen, and managed the evacuation process. Residents were outside for approximately 30 minutes before being cleared to return to the building. Despite the potential severity of the situation, no residents experienced adverse effects, and medical records indicated that all residents were evacuated and returned without any change in condition. The facility's administrator did not report the incident to the state, citing a lack of instruction from the corporate office regarding the reportability of the event. The facility's policy on abuse and neglect requires immediate reporting of incidents that may adversely affect residents' health or welfare, but this protocol was not followed. The maintenance director confirmed that a plumber was called the following day to repair the leak, and the fire department had cleared the facility for re-entry. The failure to report the incident in a timely manner could have placed residents at risk for further neglect and injury.
Failure to Complete Accurate PASARR Screening
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASARR) Level I screenings were completed correctly, resulting in a deficiency for a resident with a mental illness. Specifically, a resident was admitted with diagnoses of bipolar disorder, epilepsy, and a history of traumatic brain injury, yet their PASARR Level I did not indicate a diagnosis of mental illness or intellectual and developmental disabilities (IDD). This oversight was identified during a review of the resident's records, which showed that the resident was on antipsychotic medication for bipolar disorder and had impaired cognitive function and thought processes. The Regional MDS coordinator acknowledged that the resident should have had a positive Level I PASARR due to the presence of mental illness and IDD. The coordinator noted that the PASARR was completed before her tenure and should have been verified upon admission. The facility's policy requires PASARRs to be obtained and completed accurately within 72 hours of admission, but this was not adhered to in this case. The administrator admitted that the PASARR should have been checked and corrected to ensure the resident received the necessary services.
Non-compliance with Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen sanitation review. On the initial tour of the kitchen, it was noted that the Dietary Manager (DM) was wearing a hair net that did not fully restrain her hair, leaving hair loose at her face and neck while preparing food for lunch. Additionally, the Dietary Aide (DA) was observed handling groceries in the walk-in refrigerator and freezer without wearing a beard restraint, despite having a beard and mustache. These observations were made during the preparation of lunch, where the DM was assisting with dishes and preparing pureed meals, and the DA was preparing desserts, both without proper hair and beard restraints. Interviews conducted during the survey revealed a lack of awareness and compliance with the facility's sanitation policy. The DA admitted to not being informed about the necessity of wearing a beard net and mentioned that the facility was in the process of ordering them. The DM acknowledged that all hair should be restrained under a hair net and that staff with facial hair should wear beard restraints. The facility's policy on sanitation and personal hygiene, dated October 2023, clearly stated that all staff handling food must follow hygiene procedures to prevent foodborne illness, including wearing hair and beard restraints. The Administrator confirmed the expectation for staff to wear these restraints to prevent food contamination and maintain residents' trust in the kitchen's food safety.
Medication Management Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in missed medication doses. One resident, diagnosed with Parkinson's disease, did not receive three doses of her prescribed carbidopa-levodopa, which is crucial for managing her tremors. The missed doses occurred because the medication was not reordered in time, and the last available pill was administered in the morning. The LVN on duty, who was unfamiliar with the facility's medication reordering process, attempted to order the medication, but it had not arrived by the time the subsequent doses were due. This led to the resident experiencing increased tremors. Another resident, who suffers from chronic pain, did not receive her prescribed pregabalin for several doses over a few days. The issue arose from a miscommunication regarding the need for a new prescription, which was not obtained in a timely manner. Additionally, the resident was unable to receive diphenhydramine, an over-the-counter medication, as it was not in stock. The resident reported that her family had to purchase the medication from a drugstore to help her sleep, as she was not taking her pain medication at the time. Interviews with facility staff, including the DON and the facility physician, revealed that there was a lack of a systematic approach to ensure medications were reordered before running out. The DON, who had recently joined the facility, identified the problem and noted that the previous system was disrupted when the former DON and some nurses left. The facility physician acknowledged the potential impact of missed doses on the residents' conditions, emphasizing the need for a reliable medication ordering system.
Privacy Breach During Facility Celebration
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information, affecting two residents. During a facility celebration for CNA week, staff took pictures in the conference room, inadvertently capturing and posting on Facebook sensitive information. Resident #1's credit card information was left unprotected and visible in the background of a photo, while Resident #2's medical information was similarly exposed on a whiteboard. This breach of privacy was observed and documented, highlighting a lapse in safeguarding resident information. The report details the medical conditions of the affected residents, with Resident #1 having severe cognitive impairment and requiring assistance with activities of daily living, and Resident #2 having moderate cognitive impairment and a history of stroke. Interviews with staff revealed that while they were generally aware of HIPAA regulations and took steps to protect resident information, the incident occurred due to a last-minute decision to use the conference room for the celebration. The facility's administrative staff acknowledged the breach and discussed the potential risks of exposed information, although no grievances were filed regarding privacy concerns.
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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