Broadway Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 8223 Broadway, San Antonio, Texas 78209
- CMS Provider Number
- 455467
- Inspections on file
- 38
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Broadway Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that multiple residents with dementia, behavioral disturbances, and schizoaffective disorder did not have required face-to-face physician visits documented over an extended period. Facility policy required the attending physician to evaluate residents at specified 30- and 60-day intervals and document these visits, but record review showed no physician progress notes or H&Ps authored by the physician for several residents. An NP completed assessments and H&Ps, with the physician signing but not dating at least one document, and the DON and ADM reported that the physician rounded weekly and signed NP notes, yet they could not produce any physician-written progress notes or H&Ps for the residents involved.
A resident with complex cardiopulmonary conditions had a critical CO2 lab value reported to an LVN, who documented that the NP and DON were informed but did not complete a change-of-condition assessment, did not document vital signs, and did not document any notification to the resident or the resident’s representative. Another LVN later phoned the NP about the critical lab but failed to document that contact. The DON and NP reported that the first LVN used unsecured text/email instead of required phone calls and did not follow established change-of-condition and notification protocols. The resident and the resident’s emergency contact stated they were never told about the abnormal lab result, leading to a deficiency for failure to promptly inform the resident, consult with the practitioner, and notify the resident’s representative of a significant change in condition.
An allegation of resident-to-resident abuse occurred when a cognitively impaired resident with dementia and a known history of throwing objects became upset during care and threw an empty plastic cup at a roommate who repeatedly opened the privacy curtain and made comments about the resident’s mother, causing a small skin tear over the roommate’s eyebrow that was treated on-site and followed by a room change. Despite facility policy and federal requirements mandating that alleged abuse be reported immediately but no later than 2 hours after suspicion, the ADM did not report the incident to authorities until the following day, exceeding the required timeframe and resulting in a deficiency for failure to timely report an alleged abuse incident.
A resident had a critical CO2 lab value, and nursing staff documented only that the NP and DON were informed and that the resident was stable, with no further detail on assessment or follow-up. An LVN later reported calling the NP and receiving no new orders but admitted forgetting to enter a progress note, and another LVN could not recall details of the critical lab or his documentation. The DON stated that an LVN reported assessing the resident and texting the NP and DON but did not document these actions. These omissions failed to meet the facility’s policy requiring detailed documentation of change in condition, provider notification, responses, and related care plan updates.
Two residents were not adequately protected from hazards due to lapses in supervision and environmental safety. One resident with a history of depression and suicidal ideation was able to access a razor and attempted self-injury after returning from a psychiatric hospitalization, without her care plan reflecting her increased risk or need for closer monitoring. Another resident with severe cognitive decline and a known risk for wandering was able to elope from the memory care unit due to ineffective preventive measures.
Two residents did not have their care plans updated by the interdisciplinary team after significant changes in their conditions. One resident's care plan lacked documentation of a history of suicidal ideation and a self-injury attempt, while another resident's care plan did not include the use of a geriatric chair for fall prevention, despite its use by staff. These omissions were confirmed through record reviews, staff interviews, and observations.
A resident who was discharged home with no cognitive impairment did not receive notification or a refund of over $1,000 in personal funds within 30 days, as required. The facility's business office was without a manager at the time, and the resident was unaware of the funds remaining in his account.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents were referred to as 'feeders' by staff, indicating a failure to treat them with dignity and respect. This terminology was used by a MA and LVN during meal service, despite both having received training on resident rights. The DON confirmed that such language was not acceptable, as it did not align with the facility's policy on treating residents with respect and dignity.
The facility failed to obtain informed consent for the administration of Sertraline to two residents. One resident received the medication for several months without a valid consent, while another received it for over four months without any consent. The DON confirmed these oversights, which were against the facility's policy requiring informed consent for psychotropic medications.
The facility's kitchen failed to meet professional food service safety standards, with food boxes stored on the floor, frost and ice on freezer items, and an open jelly container left unrefrigerated. The Dietary Manager confirmed these oversights, which could risk foodborne illness for residents.
A facility failed to maintain proper infection control practices for two residents. An LVN did not wear a gown or gloves while performing an accu-check and administering medication to a resident under contact isolation precautions. Additionally, the LVN did not wear gloves during an accu-check for another resident with diabetes and a foot ulcer. The DON confirmed the need for PPE in these situations, highlighting a lapse in adherence to infection control policies.
The secure unit's lobby area in the facility was found to have a strong urine odor, creating an unpleasant environment for residents, staff, and visitors. Observations confirmed the odor, with no apparent cause identified, and residents appeared clean. LVN C and a frequent visitor acknowledged the smell, while the Housekeeping Supervisor was unaware but planned to address it. The facility's policy on minimizing institutional odors was not followed.
A facility failed to ensure a resident's OOH DNR order was completed and included in the medical record. The resident, with severe cognitive impairment and serious health conditions, was admitted with a DNR status, but the form was missing from the records. Interviews revealed the form might have been misplaced during a hospital transfer, contrary to facility policy requiring advance directives to be readily retrievable.
The facility failed to store controlled medications in a permanently affixed compartment in the A-Hall medication room. A miniature refrigerator contained a lock box with Morphine Sulfate, which was not permanently affixed and could be easily removed. The DON confirmed the oversight, and the facility's policy lacked guidance on permanent affixation, contrary to 42 CFR 483.45 (h)(2) requirements.
A resident's medical records were incomplete, missing documentation of two unwitnessed falls and behaviors requiring PRN medication. Despite facility policies, staff failed to document these incidents, hindering proper care and monitoring.
A resident with severe medical conditions was not monitored for side effects of Aspirin and Ticagrelor, antiplatelet medications, due to a lack of comprehensive care planning. Facility staff, including the LVN responsible for care plans and the DON, failed to include monitoring instructions in the care plan, despite the known risks of bleeding associated with these medications. This oversight was evident during an observation where the resident showed signs of potential bruising or bleeding.
The facility failed to ensure menus met residents' choices and did not have a method to inform them of menu substitutions, leading to dissatisfaction and poor intake. Multiple residents expressed concerns about food quality and lack of notification about changes, and grievances were submitted without noticeable improvements.
The facility failed to provide accessible call lights for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Both residents' call lights were out of reach, which was confirmed by staff and observed during a survey.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation by not completing annual Employee Misconduct Registry searches for two staff members, LVN A and CNA B. The HRD and ADM, both new to their roles, discovered missing records and could not locate evidence of the 2023 searches, raising concerns about potential risks to residents.
Failure to Ensure Required Physician Face-to-Face Visits and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were seen face-to-face by a physician at the required intervals and that the physician documented these visits in the medical record, as required by facility policy. Surveyors determined that four residents did not have physician progress notes or history and physical (H&P) examinations completed by their physician for a one-year period. Facility policy dated 08/2020 required the attending physician to evaluate residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with documentation of these visits in the health record. One affected resident had dementia with agitation and stimulant-induced anxiety disorder, a BIMS score of 8/15 indicating moderate cognitive impairment, and a care plan addressing cognitive impairment and behavioral issues such as throwing items at others, with interventions including monitoring behavior episodes and documenting potential causes. Another resident had unspecified dementia with behavioral disturbance and a care plan for impaired cognitive function, including using yes/no questions to determine needs. For this resident, an NP completed a history and physical, which was signed but not dated by the physician. A third resident had dementia with anxiety, a BIMS score of 15/15 indicating no cognitive impairment, and a care plan for impaired cognitive function with interventions such as identifying oneself at each interaction and maintaining eye contact. The fourth resident had schizoaffective disorder, bipolar type, with a BIMS score of 15/15 and a care plan for mood problems related to bipolar disorder, insomnia, depression, and anxiety, including risk for mood changes related to pain or discomfort and use of anticonvulsant medications for bipolar disorder. Review of the electronic health records for all four residents showed no physician progress notes, assessments, or H&Ps completed by their physician from 3/27/25 to 3/27/26. During interviews, the DON and ADM stated that the residents’ physician rounded on Wednesdays and signed off on NP notes, but they were unable to provide any written physician progress notes or H&Ps authored by the physician, other than the NP’s H&P for one resident that was signed but undated by the physician.
Failure to Notify Resident, Practitioner, and Representative of Critical CO2 Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident, the resident’s practitioner, and the resident’s representative of a significant change in condition related to a critical laboratory result. The resident was admitted with multiple serious cardiopulmonary diagnoses, including heart failure, obstructive sleep apnea, chronic pulmonary edema, and acute and chronic respiratory failure with hypoxia. Her admission MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and her care plan included monitoring for altered respiratory status and reporting signs and symptoms of respiratory distress to the physician as needed. A lab report dated 3/2/26 showed a critical CO2 value of 42 (reference range 21–31), flagged as a critical result, and documentation showed that LVN A was notified of this critical lab in the evening. In response to the critical lab, LVN A entered a progress note in the early morning hours stating that the resident had a critical CO2 result of 42, that the NP and DON were informed, and that the resident was stable at that time. However, there was no further documentation by LVN A describing a change of condition assessment, vital signs, or notification of the resident or her representative, and no change of condition assessment was found in the March assessments in response to the critical CO2 value. The DON later stated that LVN A had notified the NP and DON via text message rather than by phone, and that LVN A should have called the NP and DON for a critical lab, which was considered a change of condition, and should have contacted the on‑call nurse if unable to reach them. The NP reported that LVN A often did not follow protocols and that he texted her about the critical lab via his personal email, which she stated was not secure and violated HIPAA. On the following morning, LVN B documented that the night nurse had sent the results to the NP and was awaiting a response, and LVN B then called the NP to inform her of the critical CO2 value and the resident’s assessment. LVN B did not enter a progress note at that time and later stated she must have forgotten to document the call. When interviewed, the resident and her emergency contact both stated that facility staff had not notified them of any abnormal lab results, and the resident expressed that no one had talked to her about the abnormal lab and that she would have wanted the opportunity to decide whether to go to the hospital. Facility policy on change of condition required prompt notification of the attending physician and the resident or responsible party for significant changes, including serious abnormal labs, and required documentation of the time and method of physician contact and family notification. The survey findings showed that these notification and documentation requirements were not followed for this resident’s critical CO2 lab result. The facility’s own policy defined an acute change of condition as a clinically important deviation from baseline that, without intervention, may result in complications or death, and specified that serious abnormal labs required immediate physician notification, notification of nursing supervision, and prompt notification of the resident and responsible party. Interviews with LVN A confirmed his understanding that a critical lab was considered a change of condition, that he was required to assess the resident, obtain vitals, notify the NP and DON by phone, notify the resident’s representative, and document these actions, and that texting was not sufficient. Despite this, he could not recall what he did in response to this specific critical lab beyond the brief progress note, and there was no documentation that the resident or her emergency contact were informed. These actions and omissions led to the cited deficiency for failure to immediately inform the resident, consult with the physician, and notify the resident representative of a significant change in condition. The NP stated that when she was later contacted by LVN B, she understood the resident’s chronic hypercarbic respiratory failure and elevated CO2 levels and discussed that the resident was on oxygen and needed to be off due to CO2 retention. She noted that the resident was not in distress when assessed by LVN B and during her own rounding. However, the survey focused on the lack of timely, appropriate notification and documentation at the time the critical lab was first reported to LVN A, and on the resident and emergency contact’s report that they were not informed of the abnormal lab result. The combination of failure to follow the facility’s change of condition policy, failure to use appropriate communication methods with the NP and DON, failure to notify the resident and her representative, and incomplete documentation formed the basis of the deficiency.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an alleged incident of resident-to-resident abuse was reported to the appropriate authorities immediately, but no later than two hours after the allegation was made, as required by regulation and facility policy. Resident #2, who had dementia with agitation, moderate cognitive impairment (BIMS 8/15), anxiety, and a care plan noting behavior problems related to throwing items at other people, threw an empty plastic cup at his roommate, Resident #3, during care on 1/6/26 at 5:45 PM. The incident occurred when Resident #3 attempted to open the privacy curtain while staff were providing care to Resident #2, after having opened the curtain a couple of times before and making comments about Resident #2's mother. The cup struck Resident #3 and caused a small skin tear over his left eyebrow, which was treated in-house, and Resident #3 was subsequently moved to another room. The Provider Investigation Report showed that the Administrator (ADM) did not report this resident-to-resident altercation to the state survey agency until 1/7/26 at 11:04 AM, more than two hours after the allegation and outside the timeframe required for alleged abuse. The facility’s Abuse Prevention and Prohibition Program policy required that allegations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other appropriate entities. During interview, the ADM acknowledged reporting the incident within 24 hours and stated she believed the two-hour requirement applied only when serious bodily injury occurred, characterizing the two-hour reporting requirement as a technicality. This failure to follow the regulatory and policy requirement for timely reporting of alleged abuse constituted the cited deficiency.
Failure to Document Nursing Response to Critical Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident with a critical laboratory result. A progress note for this resident documented a critical CO2 value of 42 (reference range 21–31) and stated that the NP and DON were informed and that the resident was stable at that time. A subsequent note recorded that the night nurse (LVN A) reported sending the results to the NP and was awaiting a response. However, there was no further documentation by LVN A describing his assessment of the resident, any follow-up actions taken, or additional communication with the NP beyond this brief entry. Record review showed there was no change of condition assessment completed in response to the critical CO2 lab value. LVN B reported in interview that she called the NP around breakfast time regarding the critical lab and that the NP did not provide new orders, but she acknowledged she did not enter a progress note and stated she must have forgotten to document the contact and outcome. LVN A, in a telephone interview, did not remember details about receiving the critical lab or whether he wrote any notes. The DON stated that LVN A told him he had assessed the resident, found her stable, and texted the NP and the DON, but acknowledged he did not document these actions. These omissions were inconsistent with the facility’s Change of Condition Notification policy, which requires licensed nurses to document the date, time, and details of the incident and assessment, the time and method of physician contact, the response and any orders, family notification, care plan updates, and inclusion of the incident in the 24-hour report.
Failure to Prevent Resident Self-Harm and Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with a history of depression, anxiety, and a prior hospitalization for suicidal ideation, was able to access a shaving razor and attempted to injure herself by cutting her wrist. Despite her previous hospitalization for suicidal ideation and recommendations from a hospital psychiatrist for closer observation or placement in a secure unit, the resident was returned to the general population without enhanced supervision or environmental controls to prevent self-harm. The care plan did not reflect her history of suicidal ideation or the need for increased supervision, and there was no documentation of interventions specifically addressing her risk for self-injury after her return from the hospital. Staff interviews revealed that the resident's mood and behavior changes were known, and some staff expressed concerns about her safety and the appropriateness of her placement outside of a secure unit. The resident was able to obtain a razor, possibly from personal items brought in by family or from an unlocked utility room containing razors and other potentially hazardous items. The facility's policies required incident reporting for self-inflicted injuries and suicide attempts, but the administrator initially did not believe the incident required reporting. The environment was not adequately controlled to prevent access to dangerous items, and staff supervision and monitoring were insufficient to prevent the resident's self-injury. In a separate incident, another resident with severe cognitive decline and a history of wandering and exit-seeking behavior eloped from the memory care unit. The baseline care plan documented the resident's risk for elopement, but effective measures were not implemented to prevent the resident from leaving the secure area. These failures in supervision and environmental safety placed residents at risk for harm and resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Update and Revise Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, to reflect the current condition of two residents. For one resident with a history of cerebral infarction, anxiety disorder, hemiplegia, and depression, the care plan did not include documentation of a hospitalization for suicidal ideation or a subsequent attempt to injure herself. Despite clear evidence in the medical record and psychiatric evaluation indicating the resident's risk for self-harm and recommendations for closer observation, the care plan was not updated to reflect these significant events or the recommended interventions. Another resident, diagnosed with Alzheimer's disease, dementia, high blood pressure, and anxiety disorder, experienced a significant decline and multiple falls. Although the resident was provided with a geriatric chair by hospice as a fall prevention measure after a hospital visit, this intervention was not added to the care plan. Staff interviews confirmed the use of the geriatric chair for fall prevention, but the care plan only reflected other interventions such as being up at the nurses’ station when anxious and scheduled care planning with family and hospice. The omission of the geriatric chair as an intervention was acknowledged by the MDS nurse, who could not provide a reason for its absence from the care plan. The facility’s policy required that care plans be reviewed and revised upon any status change, with the interdisciplinary team collaborating on intervention options and updating the care plan accordingly. However, in both cases, the care plans were not updated to reflect significant changes in the residents’ conditions or the interventions being used, as evidenced by record reviews, staff interviews, and direct observations.
Failure to Timely Convey Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to convey a resident's personal funds within 30 days of discharge, as required. Record review showed that a male resident, who was cognitively intact at the time of discharge, had a positive balance of $1,030.01 in his personal funds account due to a Social Security deposit. The discharge was processed and accepted by the state, and the resident's account should have been closed with a refund issued within the required timeframe. However, the refund was not processed, and the resident was not notified of the remaining funds in his account. Interviews revealed that the Business Office Manager position was vacant at the time of the survey due to the sudden death of the previous manager. The administrator, who was not in position at the time of the resident's discharge, confirmed that the refund should have been processed but was unsure why it had not occurred. The resident reported being unaware of the funds and stated that he had not been informed by the facility about the deposit after his discharge.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, specifically in the case of two residents who were referred to as 'feeders' by staff members. This terminology was used by a Medical Assistant (MA) and a Licensed Vocational Nurse (LVN) when discussing the residents' needs for assistance during meals. The term 'feeders' was used to describe residents who required help with eating, which was observed during a meal service where a Certified Nursing Assistant (CNA) was assisting these residents. The use of this term was confirmed during interviews with the MA and LVN, who both acknowledged referring to residents in this manner. The deficiency was identified through observations, interviews, and record reviews, which revealed that the staff's language did not align with the facility's policy on resident rights and dignity. The Director of Nursing (DON) confirmed that referring to residents as 'feeders' was not acceptable and did not respect the individuality of the residents. Both the MA and LVN had received training on resident rights, yet the inappropriate terminology was still used, indicating a lapse in the application of this training. The facility's policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent for the administration of the psychotropic medication Sertraline for two residents. Resident #38, a man with intact cognition and diagnosed with depression, was prescribed Sertraline. Although verbal consent was reportedly obtained from the resident's representative, the consent was not signed by the LVN until several months later, rendering it invalid. The Director of Nursing (DON) confirmed that the consent process was not properly completed at the time the verbal consent was obtained. Resident #20, who has memory problems and was diagnosed with generalized anxiety disorder and major depressive disorder, was also prescribed Sertraline. The facility's records showed that the resident received the medication daily for over four months without informed consent being obtained. The DON acknowledged that this was an oversight and confirmed that the consent form was only created after a surveyor's intervention. The facility's policy requires that residents or their representatives be informed of the risks and alternatives to psychotropic medications, which was not adhered to in these cases.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Boxes of food were improperly stored on the floor in the dry goods pantry, which was confirmed by the Dietary Manager. The manager explained that a recent delivery had not been properly stored due to time constraints. Additionally, frost and ice were found to have accumulated on two boxes of food in the freezer, which the Dietary Manager acknowledged could lead to potential contamination of the food items. Furthermore, an open container of jelly, which was labeled to be refrigerated after opening, was left out on the kitchen counter instead of being stored in the refrigerator. The Dietary Manager confirmed this oversight and stated that all dietary staff are responsible for ensuring proper storage of food items. These deficiencies were identified as potential risks for foodborne illness among residents receiving meals and snacks from the kitchen.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A in handling two residents under specific care precautions. Resident #45, a man with paraplegia, a stage 4 pressure ulcer, and diabetes, was placed under contact isolation precautions due to his chronic wound and indwelling catheter. Despite the presence of a contact precautions sign and available personal protective equipment (PPE) outside the resident's room, LVN A entered the room without wearing a gown or gloves. She performed an accu-check and administered insulin and oral medications without adhering to the required contact precautions, which included wearing a gown and gloves. Similarly, LVN A did not wear gloves while performing an accu-check on Resident #23, a 65-year-old man with type 2 diabetes and a foot ulcer. LVN A stated that she typically does not wear gloves for accu-checks unless the resident has a condition like AIDS, which was not the case for Resident #23. This practice was contrary to the facility's policy, which mandates the use of gloves when there is a possibility of contact with blood or body fluids. The Director of Nursing (DON) confirmed that Resident #45 was under contact precautions and that all staff were required to wear gowns and gloves when entering his room. The DON also stated that gloves should be worn whenever there is a potential for contact with blood or body fluids, including during accu-checks. Despite having received training in infection control, LVN A did not follow the facility's policies, leading to the identified deficiencies in infection control practices.
Unpleasant Odor in Secure Unit Lobby
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the secure unit's lobby area, which was found to have a strong smell of urine. This observation was made on January 24, 2025, at 10:32 a.m., with no obvious cause for the odor identified. Residents in the unit appeared clean and well-groomed, with no personal odors detected. LVN C confirmed the presence of the unpleasant smell, noting it created an uncomfortable environment for both staff and residents. A visitor, who frequents the facility approximately five days a week, also reported that the lobby area typically had an unpleasant odor. The Housekeeping Supervisor was unaware of the issue but stated she would inspect and clean the area. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes minimizing institutional odors, which was not adhered to in this instance.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out of Hospital Do Not Resuscitate (OOH DNR) order, was completed and included in the resident's medical record. The resident, an elderly woman with severe cognitive impairment and multiple serious health conditions, was admitted with a DNR status indicated on her profile. However, the facility did not have a copy of the DNR form in the electronic health record or any other files, which was confirmed through interviews with the social worker, Director of Nursing (DON), and MDS coordinator. The absence of the DNR form was attributed to a possible oversight during the resident's transfer to the hospital, where the form might have been included in the transfer packet without a copy being retained at the facility. This oversight was contrary to the facility's policy, which requires that copies of advance directives be maintained in the resident's medical record and be readily retrievable by staff. The failure to have the DNR form on file could lead to confusion regarding the resident's end-of-life wishes.
Failure to Properly Store Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required, specifically in the A-Hall medication room. During an observation, it was noted that controlled medications were not kept in a separate, permanently affixed compartment. A miniature refrigerator with a locked padlock was found to contain a small red lock box with Morphine Sulfate 100mg containers. Although the lock box was locked, it was not permanently affixed inside the refrigerator and could be easily removed. The Director of Nursing (DON) confirmed during an interview that the lock box containing controlled medications was not permanently affixed, but believed that the double locking mechanism met the requirements. The facility's policy on controlled substances did not include information about the need for controlled medications to be stored in a permanently affixed compartment. A review of the Regulation Text for 42 CFR 483.45 (h)(2) indicated that controlled drugs must be stored in separately locked, permanently affixed compartments, which the facility failed to comply with.
Deficiency in Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #4, as required by professional standards. Specifically, the electronic medical record (EMR) did not reflect two unwitnessed falls that occurred on separate occasions. The first incident involved the resident being found lying on the floor beside the bed, and the second incident occurred when the resident was found on the floor after being placed in a chair by a hospice CNA. Despite these falls, there was no documentation in the progress notes regarding these incidents, which is a critical oversight as it prevents staff from being fully informed about the resident's condition and necessary interventions. Additionally, the facility did not document behaviors that warranted the administration of PRN medications for Resident #4. On two occasions, PRN lorazepam and Ativan/Benadryl topical gel were administered without corresponding documentation of the behaviors that necessitated these medications. This lack of documentation is problematic as it hinders the ability of healthcare providers to monitor the resident's condition and the effectiveness of the medication, potentially leading to inappropriate care. Interviews with facility staff, including LVNs and the DON, revealed that there was an expectation for documentation of falls and behaviors requiring PRN medication. However, this expectation was not met, as evidenced by the absence of progress notes and behavior documentation. The DON and other staff acknowledged the importance of such documentation for ensuring accurate resident care and monitoring, yet the oversight persisted, indicating a lapse in adherence to facility policies and procedures.
Failure to Monitor Antiplatelet Medication Side Effects
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the monitoring of side effects from the use of Aspirin and Ticagrelor, both antiplatelet medications. The resident, who had a history of severe medical conditions including Nontraumatic Acute Subdural Hemorrhage, Major Depressive Disorder, Atherosclerotic Heart Disease, Myocardial Infarction, Hypertension, and Alzheimer's Disease, was not monitored for potential side effects of these medications, which could include significant bleeding. This oversight was identified during a review of the resident's care plan, which did not include any directives for monitoring side effects despite the known risks associated with these medications. Interviews with facility staff revealed a lack of understanding and communication regarding the necessity of monitoring for side effects of antiplatelet medications. LVN B, responsible for the nursing care plans, acknowledged that monitoring for bleeding was not included in the care plan and expressed uncertainty about how such monitoring would be documented. The Director of Nursing (DON) also admitted that the omission of monitoring in the care plan did not stand out during audits, indicating a gap in the facility's care planning process. The deficiency was further highlighted by the resident's condition during an observation, where purple discoloration was noted on various parts of the body, suggesting potential bruising or bleeding. Despite the facility's policy requiring comprehensive, person-centered care plans developed by an interdisciplinary team, the lack of specific monitoring instructions for the resident's antiplatelet medications posed a risk for delayed interventions and potential health decline.
Failure to Inform Residents of Menu Substitutions
Penalty
Summary
The facility failed to ensure that menus were developed and prepared to meet the residents' choices, including their nutritional, religious, cultural, and ethnic needs, while using established national guidelines. The facility did not have a method to inform residents of substitutions to the menu, which could lead to dissatisfaction, poor intake, and diminished quality of life. Record reviews and interviews revealed that residents were not notified of menu changes, and the facility's dietary manager (DM) and administrator (ADM) had differing expectations regarding communication of these changes. The DM stated that substitutions were logged but not communicated to residents, while the ADM believed residents were informed via a whiteboard, which was not present during observation. Multiple residents expressed dissatisfaction with the food quality and lack of notification about menu changes, and grievances had been submitted without resulting in noticeable improvements. The facility's policy on nutritional procedures did not include information on informing residents about substitutions. This lack of communication and failure to meet residents' dietary needs and preferences led to the identified deficiency.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for two residents regarding the accessibility of call lights. Resident #16, a severely cognitively impaired [AGE] year-old female with chronic kidney disease, muscle weakness, cognitive communication deficit, and muscle wasting and atrophy, had her call light hanging over the headboard of her bed, out of her reach. This was observed on 02/21/2024 at 2:50 pm. A Certified Medication Aide (CMA) confirmed that the call light should not be over the headboard and acknowledged that the resident could not reach it. Similarly, Resident #17, a moderately cognitively intact [AGE] year-old female with senile degeneration of the brain, cognitive communication deficit, and cerebral infarction, had her call light on the floor under her bed, out of her reach. This was observed on 02/21/2024 at 2:54 pm. The resident confirmed she could not reach the call light, and the CMA and Licensed Vocational Nurse (LVN) both acknowledged that the call light should be within reach. The Director of Nursing (DON) also stated that call lights should be accessible to residents to request assistance, as per the facility's policy dated 09/2022.
Failure to Implement Annual Employee Misconduct Registry Searches
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for two staff members, LVN A and CNA B, by not completing an annual Employee Misconduct Registry (EMR) search. The last EMR search for LVN A was completed on 02/11/2022, and for CNA B on 01/21/2022. The facility's Abuse and Neglect policy, revised in April 2021, mandates conducting employee background checks and not employing individuals with findings of abuse, neglect, or exploitation. However, no evidence of completed recurring searches of the EMR was found within the facility policy. The HRD, who started in January 2024, discovered many personnel records were missing or misplaced and could not locate evidence of the 2023 EMR searches for LVN A and CNA B. The ADM, also new to the role as of January 2024, was unaware of the annual EMR searches for these staff members and stated it was the HRD's responsibility to ensure these checks were completed annually. Interviews with the HRD and ADM revealed that the previous HRD had informed them that EMR searches were completed in 2023, but no evidence could be found to support this claim. The HRD acknowledged her role in ensuring staff were searched for employee misconduct but could not correct past mistakes. The ADM expressed her expectation that all staff be searched annually in the EMR, including existing staff before her tenure. The lack of evidence for the annual EMR searches for LVN A and CNA B raised concerns about the potential risk to residents, as they could be cared for by staff who had committed misconduct towards residents in long-term care.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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