Brentwood Terrace Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Paris, Texas.
- Location
- 2885 Stillhouse Road, Paris, Texas 75460
- CMS Provider Number
- 676045
- Inspections on file
- 39
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brentwood Terrace Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, intact cognition, and total dependence for peri-care and bed mobility was care planned and ordered for incontinence management and skin protection, with an expectation from nursing leadership that staff round at least every two hours. On one occasion, the resident reported being left in a soiled brief for over five hours, leading to urine-saturated bed linens; an Ombudsman later found the resident crying and soaking wet and observed aides entering to provide care after the concern was raised to the ADON. Staff interviews indicated reliance on the resident’s call light use, lack of recall of the resident being soaked, and incomplete documentation of the frequency of incontinent care, demonstrating a failure to provide timely toileting and incontinent care as recommended.
A CNA failed to treat a resident with respect and dignity during assistance with a TV, including making dismissive comments and leaving the room without explanation despite the resident's confusion. The resident, who had visual and hearing impairments and was dependent on staff for various needs, reported staff rudeness and negative remarks. Interviews confirmed the CNA did not recognize the dignity issues in her actions, contrary to facility policy and expectations stated by the DON and Administrator.
A resident with quadriplegia and migraines did not receive prescribed Qulipta for three days because nursing staff failed to ensure timely pharmacy delivery and did not notify the physician or appropriate supervisory staff about the missed doses. Interviews revealed that staff were aware of the medication shortage but did not take required actions to resolve the issue or communicate the problem, contrary to facility policy.
Two residents did not receive prescribed medications as ordered, including missed insulin and blood sugar checks for a diabetic resident attending an outside program, and a missed dose of Metoprolol for another resident with a gastrostomy tube. Nursing staff failed to notify the physician or ensure medication administration in accordance with facility policy, resulting in significant medication errors.
Surveyors found that a nurse left a medication cart unlocked while unattended, and two residents had medications (an inhaler and nystatin cream) unsecured in their rooms without proper assessment for self-administration or physician orders. Facility staff were unaware of the presence of these medications at bedside, and policies requiring secure storage and assessment for self-administration were not followed.
Staff failed to follow infection control protocols by not performing proper hand hygiene and not donning required PPE, such as gowns, during incontinent care, IV medication administration, and gastrostomy tube medication administration for residents on enhanced barrier precautions. These lapses occurred despite staff training and clear signage, affecting multiple residents with complex medical needs.
A resident with severe cognitive impairment and dementia was not provided with care plan meetings that included her representative, as required. The facility did not document or conduct quarterly care plan conferences, and the resident's representative confirmed she was never invited to participate. Staff interviews revealed that the responsibility for organizing these meetings was not fulfilled, resulting in the representative's exclusion from the care planning process.
A resident with a history of behavioral issues and cognitive impairment was struck in the head by another resident with psychiatric diagnoses and poor impulse control after a dispute involving a wheelchair. The incident was witnessed by a CNA, and records showed both residents had care plans addressing their behavioral risks, but staff intervention occurred only after the physical contact had taken place.
A resident with multiple mental health diagnoses was incorrectly coded on the MDS assessment as not having a serious mental illness or intellectual disability in the PASRR section, despite care plan documentation showing PASRR positivity and related services. Staff interviews confirmed the assessment should have reflected the resident's true status, and there was no specific policy for ensuring MDS accuracy.
A resident with a feeding tube and multiple medical conditions did not receive a scheduled enteral feeding as ordered by the physician. Staff interviews confirmed that the nurse responsible did not administer the feeding, despite care plan interventions and facility policy requiring adherence to physician orders for tube feedings.
A resident with COPD was observed receiving continuous oxygen therapy without a physician's order documented in the medical record. Nursing staff and administration were unaware of the missing order until notified by surveyors, despite facility policy requiring a physician's order specifying oxygen administration details.
The facility's kitchen was found to have significant sanitation issues, including a dirty microwave, a deep fryer with old grease, and sheet pans with grease buildup. Staff interviews revealed that cleaning protocols were not consistently followed, with the microwave not cleaned after use and the deep fryer not cleaned after frying fish. The Dietary Manager and Administrator acknowledged the importance of cleanliness to prevent foodborne illness, but practices did not meet professional standards.
A CNA in an LTC facility failed to communicate with four residents during care, leading to feelings of disrespect and rudeness. Despite the residents having intact cognition and care plans emphasizing communication, the CNA did not engage with them verbally. This issue was reported by the residents, but previous complaints had not led to significant action beyond initial training.
The facility failed to address and document grievances from the resident council regarding call light response times. Despite repeated concerns raised in meetings, there was no documentation of efforts to resolve these issues. Staff interviews revealed a lack of communication and follow-up, with the Administrator admitting awareness of the ongoing problem but failing to provide documentation of grievances or resolutions.
A resident's OOH-DNR form was found incomplete, missing the physician's printed name, during a review at an LTC facility. The resident, with severe cognitive impairment due to dementia, had an active DNR order. The social worker responsible for DNRs admitted to missing this detail during random audits. The facility's administrator emphasized the importance of complete DNR documentation to respect resident preferences.
A facility failed to update a resident's care plan to reflect her current needs, as she no longer required a fall mat due to her inability to transfer or ambulate independently. Despite discussions in morning meetings, the care plan was not revised, leading to a deficiency in providing person-centered care.
The facility failed to ensure proper storage of medications for two residents, leading to medications being left at the bedside. A resident with COPD had nebulizer medication left unattended, while another resident with Parkinson's had various medications at his bedside without proper assessment for self-administration. Staff acknowledged the importance of secure medication storage to prevent misuse and ensure safety.
A resident with dementia and malnutrition did not receive her prescribed iced tea during a lunch meal, contrary to her dietary plan. The RN, DON, and Administrator acknowledged the importance of serving drinks with meals to prevent dehydration, but no monitoring system was in place prior to the surveyor's intervention.
The facility failed to provide sufficient support personnel in the kitchen, resulting in food being served at improper temperatures and meals being delayed. The cook, working double shifts due to understaffing, did not reheat food held below the required 135 degrees Fahrenheit. The Dietary Manager confirmed long-standing issues with the steam table and the stress caused by the lack of staffing.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Issues included improper thawing of meat, use of unpasteurized eggs, and failure to maintain proper food temperatures. Additionally, the three-compartment sink was not used correctly for sanitizing equipment.
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. One resident's care plan was not updated after discontinuing an antidepressant, another's was not revised after multiple falls, and a third's was not updated following consecutive falls. This led to inaccurate care information and potential risks for the residents.
The facility failed to ensure necessary grooming and personal hygiene services for seven residents, including missed baths and showers, and one resident not being shaved due to a missing razor. These deficiencies were identified through observations, interviews, and record reviews, revealing inconsistent hygiene care and resulting in feelings of uncleanliness among the residents.
The facility failed to ensure that four staff members, including two LVNs, a Social Worker, and a Housekeeping Supervisor, completed their required annual restraint training. This oversight was due to a lack of clarity and accountability in the training program, placing residents at risk for inappropriate use of restraints.
The facility failed to notify a resident's family of new skin concerns, including shearing, hematoma, bruising, and redness, despite the care plan's directives and facility policy. The lapse in communication and documentation was confirmed through record reviews and interviews with staff and family members.
The facility failed to inform a resident of changes to their Medicare/Medicaid coverage and potential out-of-pocket costs by not providing a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) upon discharge from skilled services. The MDS Coordinator admitted to forgetting the task, and the Administrator confirmed the responsibility lies with the MDS Coordinator and BOM.
A resident with multiple health issues continued to miss scheduled baths despite a grievance filed by her family member. The facility's records and interviews with staff revealed a lack of oversight and accountability in ensuring the resident received her scheduled baths, leading to ongoing dissatisfaction and potential risks for the resident.
The facility failed to ensure accurate MDS assessments for a resident, incorrectly indicating the use of an antidepressant medication that had been discontinued. The error was confirmed by the MDS Coordinator, and the DON and Interim Administrator emphasized the importance of accurate assessments.
The facility failed to implement a comprehensive care plan for a resident at risk for falls, as the required fall mat was not present at the bedside during multiple observations. Staff interviews confirmed the oversight and acknowledged the importance of the fall mat in preventing injury.
The facility failed to provide consistent and scheduled in-room activities for a resident with quadriplegia, major depressive disorder, and anxiety disorder. The resident's preferences for various activities were not care planned or documented, leading to feelings of sadness and loneliness. The Activity Director was unable to provide these activities consistently due to being overburdened and lacking assistance.
The facility failed to ensure proper treatment and services to prevent urinary tract infections for two residents. One resident's urinary catheter was not secured properly, and another resident did not receive adequate incontinent care, including improper glove changes and hand hygiene.
The facility failed to obtain weekly weights as ordered for a resident with multiple diagnoses, including dementia and malnutrition. Interviews revealed that the responsibility for obtaining weights was assigned to aides and LVNs, but the weights were overlooked on two occasions. The facility's policy required weights to be documented at admission, readmission, and monthly unless otherwise ordered.
The facility failed to provide proper respiratory care for two residents. One resident's nebulizer mask was not stored in a bag when not in use, and another resident received oxygen at an incorrect rate. These deficiencies were confirmed through observations and staff interviews, indicating non-compliance with professional standards and physician orders.
The facility failed to monitor side effects and behaviors for a resident on multiple psychotropic medications and administered PRN Clonazepam to another resident without adequate indication or prior interventions. This lack of monitoring and documentation could lead to unnecessary medication use and adverse side effects.
The facility failed to ensure all drugs were stored in a locked compartment, as a nurse treatment cart was found unlocked and unattended. The nurse on duty admitted the cart should be locked, and keys were found lying on top of the cart. Interviews with the ADON, ADM, and DON confirmed the expectation that carts be locked to prevent unauthorized access.
The facility failed to ensure appropriate antibiotic use and documentation for a resident with a UTI, leading to potential risks of unnecessary antibiotic use and increased antibiotic-resistant infections. Key protocols, including SBAR assessments and logging antibiotic use, were not followed.
Failure to Provide Timely Incontinent Care Resulting in Saturated Bed Linens
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of activities of daily living related to hygiene, grooming, and incontinent care for one cognitively intact resident. The resident, an older female with multiple medical diagnoses including cerebral infarction, COPD, dysphagia, DM2, bipolar disorder, heart failure, hyperlipidemia, CKD stage 3, and seizures, was dependent for peri-care/toilet hygiene, bed mobility, transfers, and lower body dressing, and was incontinent of bowel and bladder. Her care plan and physician orders reflected incontinence, diuretic use, and risk for skin breakdown, with topical Nystatin ordered for yeast infection in the groin and abdominal folds. The DON stated an expectation that nursing staff round at least every two hours to ensure incontinent care needs are met. On one date, the resident reported she had been left in a soiled brief for over five hours, resulting in bed linens saturated with urine. The Ombudsman corroborated that on that date, at approximately late morning, she found the resident crying and “soaking wet,” and allowed the resident to call the state hotline. The Ombudsman reported notifying the ADON and observing aides enter the room to provide peri-care while she spoke with the ADON. On a later observation date, the resident told the surveyor she was soiled with urine and waiting to be changed; the surveyor noted a slight urine odor and a brief that was not saturated and appropriately sized, and also noted the resident’s call light was not on during that interview. Staff interviews showed that CNAs, hospitality aides, an LVN, the ADON, and the DON all acknowledged the resident used XXL briefs kept in her room and typically used the call light when she needed to be changed. Multiple staff members, including CNAs and hospitality aides, stated they did not recall the resident being found soaked or excessively wet, and one CNA working the relevant hall on the date in question stated she was rushed but felt she completed her tasks, though she could not recall how often she checked on the resident. The DON and Administrator both stated expectations that incontinent care be provided as needed and that staff round at least every two hours, but the nurse aide task documentation for the date in question only showed incontinent care checked off by shift without indicating the number of times peri-care was provided. No facility incontinent care or ADL policy was reviewed prior to survey exit. The facility failed to ensure incontinent care was provided every two hours as recommended, resulting in the resident’s bed linens being saturated with urine.
Failure to Treat Resident with Dignity and Respect During Care Interaction
Penalty
Summary
A certified nursing assistant (CNA) failed to treat a resident with respect and dignity during an interaction involving assistance with the resident's television. The resident, who had chronic obstructive pulmonary disease, heart failure, anxiety disorder, visual impairment, and hearing difficulties, was dependent on staff for emotional, intellectual, physical, and social needs. The resident reported that staff were rude, spoke negatively about him, and that he had difficulty operating his TV remote due to his visual impairment. During an observation, the CNA entered the resident's room, made a dismissive comment about the resident's request for the TV, and failed to address the resident directly before leaving the room to get batteries, despite the resident expressing confusion as she exited. Interviews with the CNA revealed a lack of awareness regarding the importance of explaining actions to residents and addressing them respectfully, especially when leaving the room. The CNA did not perceive her actions as disrespectful or as a violation of the resident's dignity. The Director of Nursing (DON) and the Administrator both stated that staff are expected to explain their actions to residents and ensure their needs are met before leaving the room. The facility's policy requires that residents be treated with respect and dignity, and that their individual needs and preferences be accommodated.
Failure to Administer Prescribed Medication Due to Pharmacy and Communication Lapses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with quadriplegia and migraines. The resident did not receive his prescribed Qulipta medication on three consecutive days, as documented in the Medication Administration Records (MARs) for those dates. Interviews revealed that nursing staff were aware the medication was unavailable due to a delay in pharmacy delivery, but did not contact the pharmacy to expedite delivery or notify the physician about the missed doses. The resident reported to surveyors that he was informed by nurses that his medication was out of stock. Further interviews with nursing staff indicated a lack of clarity regarding responsibility for contacting the pharmacy and notifying the physician when medications were not available. The Director of Nursing (DON) and Administrator both stated that nurses were expected to ensure medications were administered as ordered and to notify appropriate personnel if medications were missed, but neither was made aware of the missed doses. The facility's policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this instance.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to lapses in medication administration. One resident, a male with diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive his ordered blood sugar checks or insulin for 21 out of 31 days in May. The resident attended an adult habilitation center Monday through Friday, where staff were not authorized to administer medications. Facility nurses documented the missed doses as the resident being away but did not notify the physician or ensure alternative arrangements for medication administration. The medical director and nursing staff were unaware that the resident was not receiving his prescribed blood sugar checks and insulin during his time at the center. Another resident, a male with a history of dysphagia, gastrostomy hemorrhage, muscle wasting, and hypertension, did not receive his scheduled dose of Metoprolol via gastrostomy tube at 4:00 p.m. on a specific date. The resident reported not receiving the medication, and the responsible nurse confirmed it was her duty to administer medications on time. The facility's policies require medications to be administered as ordered and for the physician to be notified if a dose is missed, but this protocol was not followed in this instance. Interviews with facility staff, including nurses, the medical director, the regional nurse consultant, and the administrator, confirmed that the expected practice was to administer medications as ordered and to notify the physician if a dose was missed. However, in both cases, the required medications were not administered as prescribed, and appropriate notifications were not made, resulting in significant medication errors for both residents.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
Surveyors identified that a registered nurse failed to secure a medication cart when leaving it unattended to check a resident's blood sugar. The nurse admitted to forgetting to lock the cart and acknowledged responsibility for ensuring it was secured. Facility leadership, including the Regional Compliance Nurse and Administrator, confirmed that medication carts are expected to be locked when unattended to prevent unauthorized access. Additionally, a resident with COPD and asthma was observed multiple times with a labeled Albuterol inhaler on her dresser, which she reported using as needed and stated she brought from home. The medication was also found on the nurse's medication cart at one point, and the resident indicated she had informed someone at the facility about possessing the inhaler, though staff were unaware. The resident had not been assessed for self-administration of medication, and the inhaler was not secured as required by facility policy. Another resident was found with a tube of nystatin cream on her bedside table, which she stated was brought by her husband and used for itching. There was no physician order for the cream, and the resident had not been assessed for self-administration. Staff later instructed the resident to have the medication removed, but were initially unaware of its presence. Facility policy requires medications to be stored securely and only accessible to authorized personnel, and mandates assessment and physician order for self-administration, which was not completed in these cases.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following proper infection control protocols during resident care. In one case, a CNA provided incontinent care to a female resident with dementia and congestive heart failure without changing gloves or performing hand hygiene between cleaning the resident's front and back areas. The CNA then touched clean items and assisted the resident to her wheelchair while still wearing the same contaminated gloves, only removing them and washing hands after completing all care tasks. Interviews confirmed that the CNA was aware of the correct procedures but did not follow them during the observed care. In another instance, an LVN administered IV medication to a male resident with sepsis and cellulitis, who was on enhanced barrier precautions (EBP), without donning a gown as required by the resident's care plan and facility policy. The LVN performed hand hygiene and wore gloves but omitted the gown, later stating that nervousness caused her to forget this step. The resident's care plan and EBP signage in the room clearly indicated the need for both gloves and gown during high-contact care activities, including IV medication administration. Additional deficiencies were observed with another male resident with quadriplegia and a feeding tube, also on EBP. An LVN administered medications via the resident's gastrostomy tube without wearing a gown, despite the presence of PPE supplies and EBP signage in the room. Furthermore, two CNAs provided personal care, including bathing, to the same resident without donning gowns. Both staff members acknowledged their training on PPE use and the importance of infection control, but failed to comply with established protocols during the observed care activities.
Failure to Involve Resident Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident's representative was invited to participate in the development and review of the resident's person-centered care plan. The resident, an elderly female with dementia, muscle weakness, and anxiety, had been admitted to the facility several months prior. Her medical records indicated severe cognitive impairment, and her care plan included interventions to communicate with the resident and her family regarding her needs. However, there was no documentation in the electronic medical record that a care plan conference had been completed or uploaded since her admission. Interviews with the resident's representative confirmed that she had not been invited to any care plan meetings since the resident's admission. Facility staff, including the social worker, registered nurse coordinator, administrator, and MDS coordinator, acknowledged that care plan meetings should occur at least quarterly and that the social worker was responsible for ensuring these meetings were conducted. Despite this, the required care plan meetings had not taken place, and the representative had not been given the opportunity to participate in the resident's care planning process.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when one resident physically struck another in the head. Specifically, a male resident with a history of dementia, Alzheimer's disease, and behavioral problems, including physical aggression, was hit in the head by a female resident diagnosed with bipolar disorder, schizophrenia, and poor impulse control. The incident occurred in the day room when the male resident reportedly ran over the female resident's foot with his wheelchair, prompting her to hit him in the head. This event was witnessed by a CNA, who heard the altercation and observed the physical contact. Record reviews indicated that the male resident had documented short- and long-term memory problems and a history of behavioral issues, while the female resident had a care plan addressing her potential for physical behaviors and poor impulse control. The care plan for the female resident included interventions for immediate staff intervention in the event of physical behaviors toward others. Despite these documented risks and interventions, the physical altercation occurred, and staff intervention only took place after the incident had already happened. Interviews with staff and residents confirmed the occurrence of the incident, with the CNA stating she intervened immediately after hearing the altercation and witnessing the physical contact. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. However, the incident demonstrated a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.
Inaccurate MDS Assessment Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with significant mental health diagnoses. Specifically, the MDS for a female resident with a history of bipolar disorder, schizophrenia, delusional disorder, and anxiety disorder was incorrectly coded in the PASRR (Preadmission Screening and Resident Review) section. The assessment marked that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation in the care plan indicating that the resident was PASRR positive and receiving habilitation coordination and independent living skills training. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Specialist, Regional Compliance Nurse, and Administrator, confirmed that the MDS should have been marked to reflect the resident's PASRR status. The Administrator acknowledged that monitoring of MDS accuracy was done through random audits or spot checks but could not recall the last audit performed. There was no specific policy or procedure in place regarding MDS assessment accuracy, and the facility relied on the RAI manual for guidance.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident who required enteral feeding via a gastrostomy tube. The resident, a male with diagnoses including dysphagia, gastrostomy hemorrhage, and muscle wasting, had physician orders for Nutren 2.0 to be administered through his PEG tube with specified flushes. The comprehensive care plan identified risks such as aspiration, weight loss, and dehydration, and included interventions to administer tube feeding as ordered. However, on a specified date, the resident did not receive his scheduled feeding, as confirmed by his own report and subsequent staff interviews. Interviews with nursing staff and facility leadership confirmed that it was the nurse's responsibility to administer the enteral feeding as ordered and that failure to do so could result in weight loss and other complications. The facility's policy assigned responsibility for tube feeding administration to the nursing service department. The deficiency was identified through record review and interviews, which established that the resident's enteral feeding was not administered according to physician orders on the specified date.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of COPD who was receiving oxygen therapy had a corresponding physician's order in her medical record. The resident was observed on multiple occasions using oxygen via nasal cannula, with the oxygen concentrator set at 2 liters per minute. The resident reported wearing oxygen at all times due to her COPD. Review of the resident's care plan indicated she was to receive oxygen therapy, but it did not specify the number of liters to be administered. Additionally, the physician order summary did not contain an order for oxygen, and the admission MDS had not yet been completed. Interviews with nursing staff and facility administration revealed that the lack of an oxygen order was not identified until brought to their attention by the surveyor. The charge nurse responsible for the resident's care and the regional compliance nurse both confirmed that an order should have been present in the electronic medical record. The facility's policy on oxygen administration requires a physician's order specifying the amount and method of oxygen delivery, which was not followed in this case.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in its kitchen, which could potentially place residents at risk for foodborne illness. During an initial tour observation, surveyors noted brown flaky debris in the microwave, dark brown grease with floating debris in the deep fryer, and three sheet pans with encrusted black colored grease buildup. These observations indicate a lack of adherence to professional standards for food safety. Interviews with staff revealed that the microwave had not been cleaned after breakfast use, and the deep fryer, which was supposed to be cleaned weekly, had not been cleaned since frying fish the previous Friday. The sheet pans were acknowledged to have carbon buildup, and there was an ongoing effort to replace them without exceeding the budget. The Dietary Manager and Administrator both recognized the importance of maintaining clean kitchen equipment to prevent foodborne illness, but the facility's practices did not align with these standards.
Failure to Communicate with Residents During Care
Penalty
Summary
The facility failed to treat four residents with respect and dignity, as evidenced by the actions of CNA A, who did not communicate with the residents while providing care. This lack of communication was reported by the residents during a group meeting, where they expressed feelings of disrespect and rudeness from CNA A. The residents involved were able to make themselves understood and had intact cognition, as indicated by their BIMS scores. Despite this, CNA A did not engage with them verbally during care, which was perceived as disrespectful. Resident #5, a female with chronic obstructive pulmonary disease, required assistance with personal hygiene and dressing. Her care plan emphasized the need for communication and cues due to her impaired cognitive function. Resident #7, diagnosed with dementia, also required assistance with personal care and had previously reported CNA A's lack of communication as rude. Resident #10, who had a cerebral infarction, needed moderate assistance and had a care plan that included explaining procedures to her. She reported feeling disrespected by CNA A's lack of communication and an overheard comment. Resident #58, with atherosclerotic heart disease, required substantial assistance and had a care plan that included communication strategies, which were not followed by CNA A. Interviews with staff, including CNA A, revealed a discrepancy between the residents' experiences and CNA A's account of her interactions. CNA A claimed to communicate with residents during care, but the residents' consistent reports of her silence suggest otherwise. The DON and Administrator were aware of past complaints about CNA A's communication, but no further action was taken beyond an initial in-service training. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Address Resident Council Grievances on Call Light Response
Penalty
Summary
The facility failed to address and document the grievances and recommendations of the resident council regarding call light response times. Over several months, the Resident Advisory Council Minutes consistently indicated that call lights were not being answered in a timely manner. Despite these repeated concerns being raised in meetings on multiple occasions, there was no documentation of efforts to resolve these issues in the facility's grievance records. Interviews with residents confirmed that they had not received any feedback or resolution regarding their complaints about call light response times. Staff interviews revealed a lack of communication and follow-up on the issue. RN D acknowledged the residents' complaints and reported them to the Assistant Directors of Nursing (ADONs), but no resolution was provided. Both ADON E and the Director of Nursing (DON) stated that they were unaware of any reports from residents or staff about the call light issues. The Administrator admitted awareness of the ongoing problem but failed to provide documentation of grievances or resolutions. The facility's grievance policy requires prompt efforts to resolve grievances, but this was not demonstrated in the handling of the resident council's concerns.
Incomplete DNR Form Lacks Physician's Printed Name
Penalty
Summary
The facility failed to ensure the right to formulate an advanced directive for a resident reviewed for advanced directives. Specifically, the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for a resident was missing the physician's printed name. This oversight was identified during a record review, which showed that the resident, a female with severe cognitive impairment due to dementia, had an active physician's order for DNR. The comprehensive care plan indicated that the resident's DNR status was to be explained to her or her responsible party, and that she was to be maintained at a level of comfort as ordered by the physician. Interviews with facility staff revealed that the social worker, who was responsible for completing DNRs, acknowledged the missing physician's printed name on the resident's OOH-DNR form. The social worker admitted to conducting random audits but could not specify the date of the last audit, indicating that the missing printed name was overlooked. The facility's administrator stated that DNRs were expected to be filled out completely, including signatures, and emphasized the importance of ensuring residents' code status was up to date to respect their preferences.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #43, which did not reflect her current needs. Resident #43, an elderly female with dementia, muscle weakness, reduced mobility, and anxiety disorder, was identified as being at high risk for falls. Her care plan, last revised on 11/26/2024, included the use of a fall mat at her bedside. However, observations on 01/06/2025 and 01/07/2025 revealed that no fall mat was present, and her order summary dated 01/07/2025 did not indicate the need for a fall mat. Interviews with nursing staff and the administrator confirmed that the care plan was not updated to reflect that Resident #43 no longer required a fall mat due to her inability to transfer or ambulate independently. The deficiency was attributed to a lack of communication and coordination among the nursing staff responsible for updating care plans. RN K and RN L indicated that the MDS team and nursing staff were responsible for updating care plans with any change in condition, but the care plan for Resident #43 was not updated despite discussions in morning meetings. The administrator acknowledged that the nursing staff should have ensured the care plan was current and reflective of Resident #43's needs. This oversight could potentially place Resident #43 at risk of not having her individualized needs met, impacting her quality of life.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs were stored in a locked compartment, accessible only by authorized personnel, for two residents reviewed for medications at their bedside. Resident #34, a male with a diagnosis of COPD, had his nebulizer medication left at his bedside on two occasions. The resident's nebulizer mask was observed to be filled with medication, which he had not yet taken. The nursing staff, including LVN F and LVN G, admitted to setting up the breathing treatment and leaving the room, without ensuring the medication was administered. Resident #34 had not been assessed for self-administration of medication, and the staff acknowledged the importance of not leaving medication at the bedside to prevent misuse and ensure the resident received the prescribed dosage. Resident #59, who has Parkinson's disease, was found with Lamisil, Cortizone-10, and Flonase at his bedside, which were not addressed in his order summary report. The resident was unable to recall the purpose of these medications, and they were reportedly brought by a family member. RN C confirmed that Resident #59 had not been assessed for self-administration, and the medications were removed from his room. The DON emphasized the necessity of completing a self-administration assessment and obtaining an order before allowing medications at the bedside. The facility's policy on medication storage requires that medications be stored safely and securely, accessible only to authorized personnel. The Administrator and other staff members reiterated the importance of storing medications properly to prevent medication errors or misadministration. Despite these policies, the facility failed to comply, resulting in medications being left at the bedside for both residents, which could lead to potential safety risks.
Failure to Provide Consistent Hydration
Penalty
Summary
The facility failed to provide liquids consistent with a resident's needs, specifically for a resident who did not receive her iced tea during a lunch meal. The resident, an elderly female with dementia and unspecified protein-calorie malnutrition, was on a regular diet with ground meat texture and thin/regular liquid consistency. Her comprehensive care plan indicated she was at risk for nutritional problems, including weight loss and dehydration, and required specific dietary interventions. On the observed date, the resident's meal ticket indicated she should receive iced tea, but it was not provided with her lunch tray. During the survey, the RN confirmed the omission of the iced tea and acknowledged its importance in preventing dehydration. The Director of Nursing (DON) and the Administrator both stated their expectations that drinks should be served with meals to ensure proper hydration. The facility's policy on hydration emphasized providing sufficient fluid intake to maintain health, but there was no system in place to monitor drink provision prior to the surveyor's intervention, as this issue had not previously occurred.
Failure to Maintain Proper Food Temperatures and Timely Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Observations revealed that food temperatures for various items, including chicken fried chicken patties and mashed potatoes, were held below the required 135 degrees Fahrenheit on the steam table. Despite knowing the correct temperature ranges, the cook did not reheat the food before serving due to being overworked and understaffed. This resulted in meals being served late and at improper temperatures over several days, increasing the risk of foodborne illness for residents. Interviews with the cook and the Dietary Manager (DM) confirmed that the kitchen was understaffed, with the cook working double shifts and the steam table malfunctioning. The DM acknowledged the long-standing issues with the steam table and the stress caused by the lack of staffing. Both the cook and the DM emphasized the importance of serving food at the correct temperatures to ensure resident safety and satisfaction. The Interim Administrator believed that the dietary staff had sufficient staffing and expected them to serve meals on time and at appropriate temperatures. However, the facility's policies on food temperature control and handling of potentially hazardous foods were not followed. The policies required hot foods to be maintained at 140 degrees Fahrenheit or above, which was not achieved due to the staffing and equipment issues in the kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. During an initial tour observation, two 10-pound packages of ground hamburger meat were found floating in cool water in the sanitization sink of the three-compartment sink. This was not the correct method for thawing meat, which should have been done in a container in the food preparation sink under cool running water. The cook acknowledged the mistake, stating it was done in a hurry because the night staff did not take the meat out to thaw in time for lunch preparation. Additionally, the facility used unpasteurized eggs for sunny-side up and over easy eggs, which were served to residents. The dietary manager (DM) initially believed the eggs were pasteurized but later confirmed they were not after checking with the food supplier. The DM admitted to assuming the eggs were pasteurized when ordering from a new supplier. This oversight posed a risk of food-borne illness to the residents, especially given their susceptibility due to age. The facility also failed to maintain proper food temperatures on the steam table. During an observation, various food items, including chicken fried chicken patties and mashed potatoes, were held at temperatures below the required 135 degrees Fahrenheit. The cook and DM both acknowledged the issue, with the DM stating that the steam table had been problematic for years despite multiple repairs. The cook admitted to not reheating the food before serving due to time constraints. Furthermore, the cook did not properly use the three-compartment sink for washing, rinsing, and sanitizing blender parts, opting to dry them with paper towels instead of air drying, which is the approved method to prevent cross-contamination and ensure sanitation.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for three residents. For Resident #33, the facility did not update the care plan when his antidepressant medication was discontinued. This oversight was confirmed by the MDS Coordinator and the DON, who acknowledged that the care plan should have been updated to reflect the discontinuation of the medication. The failure to update the care plan could have led to the resident receiving the medication after it was discontinued, as the care plan would not have accurate information for those reading it. Resident #4's care plan was not revised after she experienced multiple falls on three separate dates. The comprehensive care plan did not include interventions for these falls, despite the resident being at high risk for falls due to her medical conditions. The DON admitted that interventions should have been added to the care plan for each fall and that the MDS nurses were responsible for updating the care plan. The lack of updates meant that necessary fall interventions were not communicated to the staff, potentially increasing the risk of further falls. For Resident #130, the facility did not update the care plan after the resident experienced falls on two consecutive days. The comprehensive care plan did not include new interventions following these incidents. Interviews with the staff revealed that the floor nurses were not responsible for updating the care plans, and the DON was unaware of the need for updates. The failure to revise the care plan after each fall meant that the staff did not have an accurate picture of the resident's care needs, which could lead to further falls and injuries. The Regional Compliance Nurse confirmed that the DON was responsible for updating the acute care plans, and the lack of updates could result in an inaccurate understanding of the resident's care requirements.
Failure to Provide Routine Hygiene Care
Penalty
Summary
The facility failed to ensure necessary services to maintain grooming and personal hygiene for seven residents. Specifically, the facility did not routinely shower or bathe six residents and failed to shave one resident. These deficiencies were identified through observations, interviews, and record reviews, revealing that the residents did not receive their scheduled baths or showers, and one resident was not shaved due to a missing electric razor. The lack of proper hygiene care could lead to decreased quality of life and self-esteem for the residents involved. Resident #22, a male with pneumonia, stroke, and hemiplegia, reported not receiving a bed bath for three weeks, despite being scheduled for baths three times a week. Similarly, Resident #67, a male with muscle weakness and lung cancer, did not receive his scheduled baths regularly. Both residents expressed feelings of uncleanliness due to missed baths. Additionally, Resident #57, a female with heart failure and anxiety, had inconsistent bath schedules, causing concern for her family members who had to remind staff of her bath days. Resident #36, a female with metabolic encephalopathy and severe obesity, preferred showers but often received bed baths due to staffing issues. Resident #9, a female with dementia and diabetes, also missed her scheduled showers, leading to feelings of uncleanliness. Resident #179, a male with quadriplegia, reported not receiving his scheduled bed baths, resulting in a musty body odor. Lastly, Resident #41, a male with dementia and high blood pressure, was not shaved for a week due to a missing electric razor, which had not been replaced or reported as a grievance. The facility's staff, including CNAs, nurses, and management, acknowledged the issues but failed to ensure consistent hygiene care for the residents.
Failure to Maintain Annual Restraint Training for Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for existing staff, specifically regarding annual restraint training. This deficiency was identified for four employees: two Licensed Vocational Nurses (LVN QQQ and LVN C), a Social Worker (SW), and a Housekeeping Supervisor. All four employees, hired on the same date, did not complete their required annual restraint training. The Corporate HR Specialist confirmed that the last restraint training for these employees was completed in January 2023, and they should have completed their annual training by February 2024. The HR Coordinator was responsible for ensuring the completion of these trainings but was unsure how the oversight occurred, citing time constraints and daily checks that failed to catch the lapse. The Director of Nursing (DON) and the Interim Administrator both expressed that they expected the annual restraint training to be completed and acknowledged that the HR Coordinator was responsible for this task. The facility's policy on New Employee Orientation did not address the requirement for annual training, contributing to the oversight. Interviews with the Corporate HR Specialist, HR Coordinator, DON, and Interim Administrator revealed a lack of clarity and accountability in ensuring the completion of required annual trainings. The HR Coordinator mentioned that staff who did not complete the required trainings were subject to in-service and disciplinary actions, but this process did not prevent the lapse in training. The deficiency places residents at risk for inappropriate use of restraints, as staff without up-to-date training may lack the necessary knowledge to handle restraints properly. The facility's failure to maintain an effective training program highlights a significant gap in their compliance with regulatory requirements.
Failure to Notify Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's representative immediately when there was a significant change in the resident's physical status. Specifically, the facility did not inform the family of new areas of shearing, hematoma, bruising, and redness found on the resident. This failure was identified during a review of the resident's records and interviews with staff and family members. The resident, an elderly female with multiple diagnoses including heart failure, atrial fibrillation, and protein-calorie malnutrition, had a care plan that required family notification of any new skin breakdowns. However, the family was not informed of the new skin concerns discovered on a specific date, despite the care plan's directives and the facility's policy on notifying family members of significant changes in status. The resident's weekly skin assessment did not document the new areas of concern, and the progress note from the same date also failed to indicate that the family had been notified. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that although the Medical Director (MD) had assessed the resident and discussed the findings with the nursing staff, there was no documentation to confirm that the family had been informed. The ADON mentioned that if it was not documented, it was not done, highlighting a lapse in communication and documentation. Further interviews with the resident's family confirmed that they were not notified of the new skin issues and only discovered them when assisting the resident themselves. The Interim Administrator acknowledged that the family should have been notified and that it was the nurse's responsibility to do so. The facility's policy on notifying the physician and family of changes in status was not followed, leading to a significant deficiency in communication and care for the resident.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to ensure that each resident was informed before, or at the time of admission, and periodically during their stay, of services available in the facility and of charges for those services, including services not covered under Medicare/Medicaid. Specifically, the facility did not provide Resident #57 with a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when she was discharged from skilled services before her covered days were exhausted. This failure was identified during an interview and record review, which revealed that Resident #57, a female with heart failure and weakness, was not informed of her options to continue services at her own expense. The MDS Coordinator admitted to forgetting to provide the SNFABN form because she was filling in for another coordinator who was typically responsible for this task. The Administrator confirmed that the MDS Coordinator and the Business Office Manager (BOM) were responsible for completing the SNFABN forms and emphasized the importance of this process to inform residents or their families about the discharge from skilled services and their right to appeal. The failure to provide the SNFABN form could result in residents not being aware of changes to their provided services and potential out-of-pocket costs.
Failure to Resolve Grievance Regarding Resident's Bathing Schedule
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who had issues with receiving baths. The resident, an elderly female with multiple diagnoses including heart failure, atrial fibrillation, and anxiety, had a grievance filed by her family member regarding her care, specifically about missed baths. Despite the grievance being marked as resolved, the resident continued to miss scheduled baths on multiple occasions, as confirmed by the resident's family member and facility records. The family member expressed frustration over the inconsistency and lack of follow-up from the facility staff, including the previous administrator's unhelpful response to their concerns. The resident's comprehensive care plan indicated she required assistance with bathing, and her medical records showed she was moderately impaired cognitively but did not refuse care. However, the facility's records revealed that the resident missed several scheduled baths, and there was no documentation of refusal. Interviews with the Director of Nursing (DON) and the Interim Administrator highlighted a lack of oversight and accountability in ensuring the resident received her scheduled baths. The DON admitted to not reviewing reports on completed showers, and the Interim Administrator acknowledged the unresolved nature of the grievance. The facility's grievance policy mandates prompt efforts to resolve grievances, but the continued issues with the resident's bathing schedule indicate a failure to adhere to this policy. The resident's family member had to repeatedly voice concerns, and there was no effective resolution or follow-up, leading to ongoing dissatisfaction and potential risks for the resident. The facility's staff, including the social worker and management, did not adequately address the grievance, resulting in the deficiency noted in the report.
Inaccurate MDS Assessment for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for one of the 24 residents reviewed for MDS assessment accuracy. Specifically, Resident #33's significant change in status MDS assessment inaccurately indicated that the resident had received an antidepressant medication within the 7-day look-back period. However, a review of Resident #33's medication administration records showed that the antidepressant medication, Celexa, had been discontinued prior to the look-back period. This discrepancy was confirmed by the MDS Coordinator, who acknowledged the error and was unsure how it occurred. The Director of Nursing (DON) and the Interim Administrator both stated that they expected MDS assessments to be accurate and that the MDS Coordinator was responsible for ensuring this accuracy. Resident #33, a male with diagnoses including dementia, major depression, and bipolar disorder, had been taking Celexa for depression until it was discontinued on January 27, 2024. Despite this, the MDS assessment dated after this discontinuation inaccurately coded the resident as having received the medication. The facility did not have a specific policy on MDS accuracy but followed the Resident Assessment Instrument (RAI) manual. Interviews with the DON, the RNC, and the Interim Administrator all highlighted the expectation for accurate MDS assessments and the potential risk of inaccurate assessments not reflecting the resident's true care needs.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #70, who was at risk for falls and required a fall mat at the bedside. Despite the care plan and order summary indicating the need for a fall mat, observations on multiple occasions revealed that Resident #70 did not have a fall mat at the bedside. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed that the fall mat was not in place and that it was the nursing staff's responsibility to ensure its presence. The staff acknowledged the importance of the fall mat in preventing injury and admitted that it might have been moved and not replaced. Resident #70, a [AGE] year-old male with severe cognitive impairment and muscle weakness, was admitted to the facility with a diagnosis of unspecified dementia. The resident's Quarterly MDS assessment indicated a BIMS score of 6, reflecting severe cognitive impairment. The care plan dated 01/19/2024, and the order summary dated 03/02/2024, both specified the need for a fall mat at the bedside. However, during observations on 02/26/2024, the fall mat was missing, and staff interviews revealed a lack of awareness and adherence to the care plan, leading to potential harm for the resident.
Failure to Provide Consistent In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for one resident. Specifically, the facility did not provide consistent and scheduled in-room activities for a resident with quadriplegia, major depressive disorder, and anxiety disorder. The resident's comprehensive MDS assessment indicated a preference for various activities, but these were not care planned or documented in the resident's electronic health record for the past 30 days. Interviews with the Activity Director (AD) and the Administrator revealed that the AD was responsible for in-room activities but was unable to provide them consistently due to being overburdened with other tasks. The AD admitted to not having a schedule for in-room activities and mentioned that she had requested assistance multiple times without success. The resident expressed feelings of sadness and loneliness due to the lack of in-room activities, which were supposed to provide social interaction and a sense of purpose. The facility's Activity Policy & Procedure Manual indicated that individualized activity programs should be provided regularly, but this was not adhered to in this case.
Failure to Provide Proper Catheter and Incontinent Care
Penalty
Summary
The facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for two residents reviewed for indwelling urinary catheters and incontinent care. Resident #179's urinary catheter was not properly secured to his leg, despite an order to ensure the catheter strap was in place every shift change. During an observation, the resident mentioned that a nurse had informed him that they did not have the supplies to secure the catheter. Interviews with the Administrator, LVN, and DON confirmed that it was the nurses' responsibility to secure the catheter properly to prevent it from being pulled out and causing trauma. Resident #53 was not provided proper incontinent care. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was found to have a bowel movement during an observation. The CNA performed inadequate cleaning, failed to change gloves between dirty and clean tasks, and did not perform hand hygiene. The CNA also failed to cleanse the resident's peri area properly. Interviews with the ADON and DON revealed that the CNA did not follow proper procedures for incontinent care and hand hygiene, which could lead to infections and skin conditions. The facility's policies and procedures for foley catheters and perineal care were not followed, as evidenced by the observations and interviews. The DON and Administrator acknowledged the importance of proper catheter securing and incontinent care to prevent infections. The Regional Compliance Nurse noted that the CNA was nervous during the observation but had passed skills check-offs. The facility's failure to adhere to these policies placed residents at risk for urinary tract infections and other complications.
Failure to Obtain Weekly Weights as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, specifically by not obtaining weekly weights as ordered by the physician. Resident #33, a male with diagnoses including dementia, unspecified protein calorie malnutrition, major depression, and bipolar disorder, was identified as at risk for malnutrition. The care plan required weekly weights for at least four weeks or until the resident's weight stabilized. However, the facility did not obtain the resident's weight on two of the specified dates, 02/13/24 and 02/27/24, as documented in the treatment administration record and electronic medical record. Interviews with the Director of Nursing (DON), an LVN, and the Interim Administrator revealed that the responsibility for obtaining weights was assigned to the transport aide and aides or LVNs. The DON emphasized the importance of obtaining weights to monitor nutritional status, while the LVN acknowledged awareness of the missed weights but stated they were overlooked. The Interim Administrator also expected weights to be obtained as ordered but was unsure if a monitoring system was in place. The facility's policy required weights to be documented at admission, readmission, and monthly unless otherwise ordered by the physician or dictated by the resident's condition.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided such care consistent with professional standards of practice. For Resident #6, the facility did not store the nebulizer mask in a bag when it was not in use. During an observation, the nebulizer mask was found laying on top of the nebulizer machine, uncovered. Interviews with the LVN and DON confirmed that the nebulizer mask should have been stored in a bag to prevent infection and ensure cleanliness. The failure to store the nebulizer mask properly could lead to bacterial pneumonia or aspiration due to inhaling bacteria from the uncovered mask. For Resident #227, the facility did not administer oxygen as ordered by the physician. The resident was observed receiving oxygen at 3 liters per minute (l/min) via nasal cannula, while the physician's order specified 2 l/min. Multiple observations confirmed the incorrect oxygen rate, and an interview with the RN revealed that the order had not been updated correctly. The DON and Interim Administrator both acknowledged that the oxygen should have been set at the prescribed rate, and the failure to do so could result in the resident not receiving the appropriate amount of oxygen. These deficiencies highlight the facility's failure to adhere to proper respiratory care protocols, potentially placing residents at risk for respiratory complications. The observations and interviews indicate a lack of compliance with professional standards and physician orders, which could negatively impact the residents' health and quality of care.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #179 was monitored for side effects and behaviors related to the use of multiple psychotropic medications, including Buspirone, Clonazepam, Lexapro, and Trazodone, since his admission. Despite the resident's complex medical history, including quadriplegia, major depressive disorder, and anxiety disorder, there was no documentation of behavior or side effect monitoring in the resident's Treatment Administration Record (TAR) for February 2024. This lack of monitoring was confirmed by the Director of Nursing (DON), who acknowledged the importance of such monitoring to ensure the medications' effectiveness and to prevent adverse side effects. Additionally, the facility failed to ensure that Resident #52's PRN Clonazepam was administered with an adequate indication for its use on two occasions. The resident, who has severe cognitive impairment and a history of anxiety and depression, received Clonazepam without documented behaviors or interventions prior to its administration. The progress notes for these dates did not indicate any specific behaviors or interventions attempted before administering the medication. Interviews with the DON and a Licensed Vocational Nurse (LVN) revealed that non-pharmacological interventions should have been attempted and documented before administering PRN psychotropic medications. The facility's policies and procedures require that all PRN medication orders specify the reason and frequency for use, and that behavior and side effect monitoring be documented. However, these protocols were not followed for Residents #179 and #52, leading to the administration of potentially unnecessary psychotropic medications without proper monitoring. This failure could place residents at risk of adverse side effects and decreased quality of life.
Failure to Secure Nurse Treatment Cart
Penalty
Summary
The facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly. During an observation and interview, a nurse treatment cart was found unlocked and unattended in the hallway. The nurse on duty admitted that the cart should be locked and that she did not know who last accessed it. Keys were also found lying on top of the cart, further compromising security. The nurse acknowledged the importance of keeping the cart locked to prevent residents from accessing potentially harmful medications and supplies. Interviews with the Assistant Director of Nursing (ADON), Administrator (ADM), and Director of Nursing (DON) revealed that they all expected the nurse treatment carts to be locked and the keys to be kept with the nurse. They emphasized the potential harm that could result from unauthorized access to the cart, including residents ingesting or using harmful substances. The facility's Medication Administration policy also required that medication carts be locked after use, but this protocol was not followed in this instance.
Failure to Promote Antibiotic Stewardship
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring the appropriate use of antibiotic therapy and not providing a written rationale when an antibiotic was used despite criteria. Specifically, the facility did not assess Resident #5 using established criteria to determine if her UTI met the criteria for antibiotic use. Additionally, the facility did not ensure an SBAR was performed to indicate a change of condition when Resident #5 exhibited signs and symptoms of a UTI. Resident #5, a female with Alzheimer's disease, was admitted to the facility and had a history of UTIs. Despite having a high range of Escherichia coli in her urine, there were missing assessments and no SBAR completed during the month of February 2024. The resident received antibiotics from February 8 to February 15, 2024, but her antibiotic use was not logged in the antibiotic log for February 2024. Interviews with staff revealed inconsistencies in following the protocol for assessing and documenting antibiotic use. The facility's Antimicrobial Stewardship policy required a complete assessment using established protocols and an SBAR assessment when a resident's condition changed. However, these steps were not followed for Resident #5. The DON and ADON acknowledged the importance of these protocols but were unsure why the required forms and logs were not completed. The failure to follow these protocols could lead to unnecessary antibiotic use and increased antibiotic-resistant infections.
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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