Brownsville Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsville, Texas.
- Location
- 320 Lorenaly Dr, Brownsville, Texas 78520
- CMS Provider Number
- 676083
- Inspections on file
- 33
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Brownsville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with advanced dementia continued to receive Depakote despite repeated requests from the resident's representative to discontinue the medication. The DON did not stop the medication immediately, citing the need to consult with the PCP, and conflicting accounts emerged regarding communication with medical providers. Facility staff interviews revealed inconsistent understanding and lack of policy on handling requests to stop medications, resulting in the resident's right to refuse treatment not being upheld.
A resident with Alzheimer's disease and dementia was started on Depakote for mood disorder, but the care plan was not updated to reflect this new intervention as required by facility policy. Staff interviews and documentation confirmed that the care plan was not revised after the medication was initiated, despite procedures mandating such updates for psychoactive medications.
A resident with Alzheimer's Disease and dementia did not receive care in accordance with professional standards when the facility failed to consult the physician before discontinuing Depakote at the request of the resident's representative. The DON was unable to reach the physician's office over the weekend and did not document any follow-up, and the resident's representative was not updated about the resident's status or change in condition.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Multiple residents with infections or indwelling devices did not receive proper infection control precautions, including lapses in contact isolation and Enhanced Barrier Precautions. Staff were observed not wearing required PPE, not following hand hygiene protocols, and misunderstanding when to apply gowns and gloves, despite facility policies referencing CDC guidelines.
Two residents with severe cognitive impairment were found to have an unlabeled bottle containing a strong chemical substance left hanging on the handrail in their shared bathroom. Staff were unaware of the bottle's origin, and it was not labeled or secured as required. Both residents required a structured, secure environment due to dementia and cognitive deficits, and the facility lacked a specific policy on chemical labeling or storage in resident areas.
A deficiency was cited when a resident was not provided with enough food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident with multiple chronic conditions was observed receiving oxygen at 3 LPM via nasal cannula, contrary to the physician's order for 2 LPM. The resident was unaware of the correct setting, and the assigned LVN confirmed the discrepancy, stating she had previously set it correctly and was unsure who changed it. The DON indicated that nurses are responsible for checking oxygen settings per shift and following orders, but the facility lacked a specific policy for oxygen administration.
A medication cart on the 400 Hall was found unlocked and unattended while the assigned Med-Aide was off the unit. Staff interviews confirmed knowledge of the requirement to keep medication carts locked when not in use, and facility policy mandates that carts remain secured at all times when unattended.
A resident with severe cognitive impairment and dysphagia was served a mechanically altered meal instead of the physician-ordered pureed diet and nectar thickened liquids. Staff failed to identify the error before serving, despite clear dietary orders and care plan documentation. The facility's tray-checking procedures and staff oversight were insufficient, resulting in the resident receiving an inappropriate meal and experiencing coughing during the meal.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not report alleged abuse, neglect, and resident-to-resident altercations to the State Survey Agency within required timeframes. For example, a resident's serious injury from a fall was not reported until after a second x-ray confirmed the fracture, and multiple altercations and unwitnessed injuries involving two residents were not reported as required. Staff interviews revealed inconsistent understanding of reporting protocols, and the facility's policy for immediate reporting was not consistently followed.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors. This lapse involved inadequate protection and management of confidential information and documentation.
Two residents were administered psychoactive medications, including antipsychotics and anxiolytics, without obtaining proper informed consent from their representatives as required by policy. In both cases, medications were given before consent forms were signed or completed, and in one instance, a consent form was missing entirely. Staff interviews confirmed that the required process for obtaining and documenting consent was not consistently followed.
A resident with severe cognitive impairment and multiple diagnoses was administered Haldol for agitation without a documented psychiatric evaluation, despite facility policy and staff statements requiring such an assessment prior to antipsychotic use. Progress notes and interviews confirmed the absence of the required evaluation before the medication was given.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
The facility did not complete the care plan within 7 days of the comprehensive assessment and failed to ensure it was prepared, reviewed, and revised by a team of health professionals as required.
A resident did not receive sufficient food and fluids to maintain their health, as required. The report identifies a failure to meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
A resident with severe cognitive impairment and no documented behavioral symptoms was administered Haldol without a valid physician's order or documented indication for use. The medication was given based on a verbal order from a nurse practitioner, but the order was not entered into the MAR and lacked required details. Staff interviews confirmed that the order was incomplete and not properly verified before administration, contrary to facility policy.
A resident with severe cognitive impairment and no documented behavioral symptoms was administered Haldol without an approved psychiatric diagnosis or informed consent, despite pharmacy consultant recommendations. Staff interviews and record reviews confirmed that required evaluations and documentation were not completed prior to the administration of the antipsychotic, in violation of facility policy.
A resident with dementia and no documented behavioral symptoms was administered Haldol, an antipsychotic, without a clear clinical indication or proper documentation. The order for the medication was inconsistently recorded, and staff interviews revealed confusion about its origin and lack of required behavioral assessments or psychiatric evaluation. Facility policy requiring informed consent and documentation prior to psychotropic use was not followed.
A resident with diabetes and multiple wounds was readmitted without physician orders for blood glucose monitoring or wound care. The LPN did not request clarification or initiate orders for these needs, resulting in the resident going several days without blood sugar checks or wound treatment. The resident experienced a hypoglycemic episode requiring hospital transfer, and wound care was delayed until several days after admission. Staff interviews revealed a lack of communication and unclear policies regarding diabetic and wound care procedures.
A resident was readmitted with multiple wounds and diabetes but did not receive timely wound care or blood sugar monitoring due to incomplete assessment, lack of communication with the NP, and failure to obtain necessary orders. The resident went five days without wound care and blood sugar checks, resulting in an episode of hypoglycemia that required hospital transfer. Staff did not follow facility policy or professional standards in documenting and reporting the resident's condition.
Three residents with complex medical needs, including diabetes and wounds, had incomplete documentation in their medical records. Nursing staff failed to sign off on physician-ordered treatments and medications, such as wound care and insulin administration, on the TAR and MAR. Staff interviews revealed that treatments were often provided but not documented due to forgetfulness or misunderstanding of documentation requirements, despite prior training and facility policy mandating accurate and timely recordkeeping.
The facility failed to develop comprehensive care plans for four residents, omitting critical details such as wound care, diet, and medication needs. A resident's care plan did not include necessary wound care instructions, while two others lacked information on diet and medication requirements despite having specific physician orders. Staff interviews confirmed these omissions, highlighting oversight and staffing issues in care plan management.
The facility failed to obtain and input orders for crushed medications for two residents, despite their dietary needs indicating a requirement for such orders. Staff relied on residents' diets to determine the need for crushed medications, leading to inconsistencies in administration. The Director of Nursing acknowledged the oversight and the necessity of having formal orders in place to prevent potential risks.
A LTC facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for four residents. A resident was found with medications left on their bedside table, and several medications were not signed off on the MAR for three other residents. Staff interviews revealed procedural lapses and personal issues contributing to these errors, highlighting deficiencies in medication handling and documentation.
The facility failed to ensure call lights were within reach for two residents with mobility impairments, risking their ability to call for assistance. Observations revealed call lights on the floor, and staff interviews confirmed the importance of accessibility, which was not maintained as per facility policy.
A facility failed to document a resident's advance directives, resulting in the absence of a code status in their records. The resident, with moderate cognitive impairment and multiple medical conditions, was defaulted to full code status due to missing DNR paperwork. Interviews with staff revealed inconsistencies in handling advance directives, with the admission nurse admitting to possibly forgetting to enter the code status.
A facility failed to complete a baseline care plan within 48 hours of a resident's admission, specifically omitting the advance directive section. The resident, with moderately impaired cognition and multiple medical conditions, had no documented code status, leading to potential misalignment with their end-of-life wishes. Staff interviews revealed confusion over responsibilities for entering and managing code status information, contributing to the deficiency.
A facility failed to update a comprehensive care plan for a resident with Alzheimer's disease, who was at high risk of elopement and placed in a secured unit. The care plan did not reflect this placement, despite the resident's severely impaired cognition. Interviews with staff revealed the omission was an oversight, with no negative outcomes reported.
A resident with severe cognitive impairment and an indwelling urinary catheter was found with catheter tubing touching the floor, contrary to care plan instructions. Interviews with staff revealed a lack of adherence to proper catheter care protocols, posing an infection control issue.
Two residents in the facility did not receive oxygen therapy according to physician orders. One resident with acute respiratory failure and other conditions received oxygen at 3.5 Lpm instead of the ordered 2 Lpm. Another resident with metabolic encephalopathy and hypoxia had oxygen set at 2.5 Lpm instead of 3.0 Lpm. Observations revealed that the oxygen machines were not set correctly, despite the facility's policy requiring adherence to physician orders and professional standards.
Two residents with histories of falls were not accurately coded in the MDS, potentially risking improper care. One resident with dementia and Parkinson's disease had an unwitnessed fall not recorded in the MDS. Another resident with Alzheimer's disease had two falls, including a witnessed fall with a minor injury, which were also not coded. The MDS Nurse and DON acknowledged these oversights, indicating a lapse in the assessment process.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
The facility failed to honor a resident's right to refuse or discontinue treatment, specifically regarding the administration of Depakote, an antipsychotic medication. The resident in question was a male with Alzheimer's disease and unspecified dementia, who was unable to communicate effectively and required significant assistance with daily activities. Despite the resident's representative (RP) explicitly requesting that Depakote be discontinued, the medication continued to be administered. The RP stated that she had not given consent for Depakote and had communicated her wishes to stop the medication during a care plan meeting attended by family members and facility staff. However, documentation of this request was not reflected in the care plan notes, and the medication was not discontinued following the RP's request. When the RP contacted the Director of Nursing (DON) to reiterate her request to stop Depakote, the DON informed her that verbal consent had previously been obtained and that the medication would not be discontinued until the primary care provider (PCP) could be consulted. The DON attempted to contact the PCP's office, but it was closed for the weekend. The DON then claimed to have spoken with a nurse practitioner (NP), who allegedly advised against discontinuing the medication until the PCP could be reached. However, subsequent interviews revealed that the NP was out of town and did not speak with the DON, and no discontinuation order was given. The RP made further attempts to communicate with the DON but did not receive a response. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Administrator, and other nurses, revealed a lack of clear policy or consistent practice regarding honoring a resident or RP's request to stop a medication. Some staff believed the medication should be placed on hold and the physician notified, while others deferred to the physician's decision even if the RP requested discontinuation. The facility's policy on resident rights emphasized the right to refuse treatment, but there was no specific policy addressing the process for discontinuing medications at the request of a resident or their representative.
Failure to Revise Care Plan After Initiation of Psychoactive Medication
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following the initiation of Depakote, an antiseizure medication prescribed for mood disorder. The resident, an elderly male with Alzheimer's disease and unspecified dementia, was admitted with significant cognitive and functional impairments, including being always incontinent, requiring maximal assistance with activities of daily living, and having unclear speech. Despite a new order for Depakote being initiated and later discontinued and re-initiated, there was no evidence that the resident's care plan was updated to reflect this change in medication as required by facility policy. Interviews with facility staff confirmed that the standard practice was for the nurse receiving the medication order to update the care plan, and that psychoactive medications should be care planned upon initiation. Documentation showed that while the medication and its purpose were discussed in a care plan meeting with the resident's representative and family, the actual care plan was not revised to address the new intervention. Facility policies required care plan updates upon status changes and initiation of psychoactive medications, but these procedures were not followed in this instance.
Failure to Consult Physician for Medication Discontinuation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consult with the resident's physician regarding the discontinuation of Depakote at the request of the resident's representative. The resident, who had diagnoses including Alzheimer's Disease and unspecified dementia, was dependent on staff for most activities of daily living and was unable to communicate effectively. The medication administration record showed that Depakote was administered as ordered until the day the resident refused a dose and later became unresponsive. Documentation revealed that the Director of Nursing attempted to contact the primary care provider's office for discontinuation orders but was unable to reach them as the office was closed for the weekend. There was no follow-up note indicating that further action was taken to obtain the necessary physician orders for discontinuation. The resident's representative reported not being updated by the facility and only learned of the resident's unresponsiveness and subsequent death after calling to follow up. The facility's charge nurse job description included the responsibility to communicate with the resident's point of contact regarding status updates or changes in condition, which was not documented as having occurred in this case.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for three residents. For one resident with ESBL and MRSA infections, staff did not enforce proper contact precautions. The resident was observed repeatedly leaving and entering his room while on contact isolation, and was allowed to share a room with another resident not on precautions, despite available single rooms. Facility leadership and infection control personnel acknowledged the lack of a specific contact isolation policy and relied on CDC guidelines, but did not consistently implement them. Another resident with MRSA in the urine and a history of multiple infections was not properly protected by staff adherence to contact isolation protocols. A CNA was observed in the resident's room without wearing any PPE, touching surfaces and the resident's belongings, and failing to perform hand hygiene after contact. The CNA admitted to not knowing the specific reason for isolation and not wearing PPE because he believed he was not in direct contact with the resident. Interviews with other staff revealed inconsistent understanding of isolation procedures and hand hygiene requirements. A third resident, who required Enhanced Barrier Precautions (EBP) due to a cholecystectomy drain, did not receive appropriate infection control measures during blood sugar checks and insulin administration. The nurse wore gloves but failed to don a gown as required by EBP protocols, despite signage and facility policy. Interviews with the nurse and DON confirmed a misunderstanding of when gowns were required under EBP, and that training had been provided but was not effectively implemented. Facility policies referenced CDC guidelines and EBP requirements, but staff actions did not consistently align with these standards.
Unlabeled Chemical Left in Shared Bathroom of Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards for two residents with severe cognitive impairment who shared a bathroom. During an observation, an unlabeled bottle containing a clear liquid with a strong chemical odor was found hanging on the handrail in the shared bathroom. Staff interviews revealed that no one knew the origin of the bottle, and it was unclear whether it belonged to the residents, housekeeping, or a family member. The bottle was not labeled, and staff acknowledged that chemicals should not be left in resident areas, especially in unlabeled containers. Record reviews indicated that both residents required a structured environment in a secure unit due to diagnoses of Alzheimer's disease, unspecified dementia, and cognitive communication deficits, with severely impaired cognition as evidenced by low BIMS scores. The facility's Safety Data Sheet for a disinfectant/detergent cleaner described the chemical as causing severe skin and eye burns and being harmful if swallowed or in contact with skin, with instructions to store it locked up. The facility did not have a specific policy on labeling chemicals or keeping them out of resident rooms, contributing to the deficiency.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide sufficient food and fluids to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is necessary to support the resident's overall well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Oxygen at Physician-Ordered Setting
Penalty
Summary
A resident with multiple diagnoses, including abnormal lung findings, dementia, congestive heart failure, chronic kidney disease, muscle wasting, type 2 diabetes, dysphagia, and hypertension, was admitted with a physician order for oxygen therapy at 2 liters per minute (LPM) via nasal cannula. The resident's care plan included interventions to address the risk for altered respiratory status, specifying that oxygen should be administered as ordered. During an observation, the oxygen concentrator was found set at 3 LPM instead of the ordered 2 LPM. The resident was in bed with the head of the bed slightly elevated and showed no signs of respiratory distress at the time of observation. The resident was unaware of the correct oxygen setting and did not recall the nurse checking the oxygen machine, although he stated the nurse had been in his room earlier. The assigned nurse confirmed the oxygen was set at 3 LPM and acknowledged the physician's order was for 2 LPM. She reported having checked the setting earlier in her shift and was unsure who may have changed it, noting the resident had received a nebulizer treatment that morning. The DON stated that nurses are responsible for checking oxygen settings once per shift and following physician orders, but also revealed that the facility did not have a specific Oxygen Administration Policy. Facility policy on medication administration required medications to be given as ordered.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart assigned to the 400 Hall Med-Aide was observed to be unlocked and unattended. The Med-Aide responsible for the cart was not present on the unit at the time of the observation. This was confirmed through interviews with the Med-Aide, who acknowledged awareness of the requirement to lock the medication cart when not in use, and with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), both of whom stated that medication carts should always be locked when unattended to prevent unauthorized access. A review of the facility's policy on medication administration and cart security, dated 10/01/19, indicated that medication carts are to be locked at all times when not in use and should not be left unlocked or unattended in resident care areas. The failure to secure the medication cart as per policy was directly observed and confirmed by staff interviews and policy review.
Failure to Provide Prescribed Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet and nectar thickened liquids was served a mechanically altered meal instead of the prescribed pureed texture. The resident, who had a history of stroke, muscle wasting, dysphagia, non-traumatic brain dysfunction, Alzheimer’s, aphasia, and severe cognitive impairment, was observed coughing after consuming the incorrect food texture. Her meal ticket clearly indicated the need for a pureed diet, but her plate contained chopped carrots, mashed potatoes, and cut-up chicken, which did not meet her dietary requirements. Nursing staff, including an RN and the ADON, acknowledged that the resident received the wrong food texture and that the error was not identified before the meal was served. The RN admitted to overlooking the pureed texture requirement on the tray card and stated that she should have returned the tray to the kitchen immediately. The process for checking trays involved both kitchen staff and nurses, but the system failed to prevent the delivery of the incorrect meal. The RN also mentioned that the resident had been refusing her pureed diet, was edentulous, and did not want to wear dentures, but these factors were not adequately addressed in the care plan or during meal service. The facility’s kitchen policy required that Nutrition & Foodservice staff check each resident’s tray card to ensure the correct diet and portion sizes, and that nurses verify trays before serving. However, interviews revealed that trays were sometimes mixed up, and the required in-services and oversight by the Registered Dietitian were lacking at the time of the survey. The absence of proper checks and adherence to dietary orders led to the resident receiving an inappropriate meal, as documented by both staff interviews and direct observation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Alleged Abuse, Neglect, and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or mistreatment to the State Survey Agency as required by regulation. Specifically, the facility did not report within the mandated two-hour timeframe when a resident sustained a serious bodily injury, nor did it report multiple resident-to-resident altercations and unwitnessed injuries within the required period. For example, one resident experienced a fall resulting in an acute distal fibular diametaphyseal fracture, but the incident was not reported to the state until after a second x-ray confirmed the injury, despite the initial x-ray already indicating a fracture. Additionally, the facility did not report two separate resident-to-resident altercations involving physical contact and aggression. In one instance, two residents engaged in a physical altercation where one struck the other, causing the second resident to stumble and then push back. These incidents were documented in progress notes and care plans, but there was no evidence that they were reported to the State Survey Agency as required. Furthermore, the facility failed to report several unwitnessed injuries and falls, including bruising, skin tears, and bumps to the head, for another resident who had a history of behavioral disturbances and unexplained injuries. Interviews with staff, including LVNs, the DON, and the Administrator, revealed inconsistent understanding and application of reporting requirements. Staff often waited for confirmation from a nurse practitioner or physician before reporting injuries, even when initial evidence suggested a serious injury had occurred. The facility's own policy required immediate reporting of all alleged violations, including those involving resident-to-resident altercations and injuries of unknown origin, but these procedures were not consistently followed.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. Specific details regarding the nature of the records or the residents affected were not provided in the report. The deficiency centers on the facility's failure to adhere to established protocols for handling and securing medical records, resulting in noncompliance with regulatory requirements for resident privacy and record maintenance.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent prior to the administration of psychoactive medications, as required by both facility policy and state regulations. In one instance, a resident with severe cognitive impairment and a history of dementia and traumatic brain injury was prescribed and administered Haldol, an antipsychotic medication, for agitation without obtaining prior consent from the resident's representative. Documentation showed that the medication was administered before the consent form was signed, and the care plan was updated to reflect antipsychotic use only after the medication had already been given. Interviews with staff confirmed that consent should have been obtained before administration, but this process was not followed in this case. In another case, a resident with Alzheimer's disease and unspecified dementia was prescribed multiple psychoactive medications, including Zyprexa, Buspirone, Lorazepam, and Risperidone. Review of medical records revealed that these medications were administered before the required informed consent forms were signed and dated by the resident's guardian or responsible party. In some instances, consent forms were missing entirely or were not properly completed. Staff interviews confirmed that the process for obtaining and documenting consent was not consistently followed, and the DON acknowledged that medications had been administered prior to receiving the necessary consents. Facility policy requires that residents and their representatives be informed of the risks, benefits, and alternatives to psychoactive medications before initiation or dose increases, and that consent be documented in advance. However, record reviews and staff interviews demonstrated that these procedures were not adhered to for the residents in question. The lack of proper consent and documentation could affect the residents' right to self-determination and informed participation in their care.
Failure to Complete Required Evaluation Before Antipsychotic Administration
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment prior to the administration of an antipsychotic medication. Record review showed that the resident, who had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage, was not evaluated before being given Haldol Decanoate for aggressive behavior. The resident's admission MDS indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis, and there was no documentation of an evaluation prior to the initiation of the antipsychotic. Progress notes confirmed that the antipsychotic was ordered and administered without a prior psychiatric evaluation, and the care plan was updated to reflect the use of Haldol for agitation. Interviews with facility staff, including a physician assistant, LVN, and the DON, confirmed that an evaluation should have been completed before administering the medication, and that no such evaluation was documented. The facility's policy also required an evaluation and documentation prior to the use of psychotropic medications, which was not followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or include clear, measurable goals and interventions.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the required timeline and interdisciplinary team involvement were not met.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Proper Physician Order and Documentation for Antipsychotic Administration
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the administration of Haldol (an antipsychotic medication). A review of the resident's records showed that there was no physician's order for Haldol Decanoate, nor was there an indication for its use documented on the order. Despite this, progress notes indicated that a nurse practitioner had given a verbal order for Haldol for aggressive behavior, and a nurse documented administering the medication. However, the medication administration record (MAR) did not contain an order for Haldol, and the order lacked the required indication for use. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The admission Minimum Data Set (MDS) indicated severe cognitive impairment, with no behavioral symptoms or indicators of psychosis, and the resident was not previously receiving an antipsychotic. The care plan was later updated to reflect the use of antipsychotic medication for agitation, but this was after the medication had already been administered without a proper order. Interviews with facility staff revealed that the medical director was not aware of the Haldol order and would not have prescribed it. Nursing staff acknowledged that all necessary checks, including consent, diagnosis, and documentation, were required before administering antipsychotics, and the Director of Nursing confirmed that the order was incomplete and not properly verified before administration. The facility's medication administration policy required verification of orders and documentation on the MAR, which was not followed in this instance.
Failure to Act on Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the consultant pharmacist were acted upon for a resident whose medications were reviewed. Specifically, recommendations from the pharmacy consultant regarding the use of Haldol, an antipsychotic medication, were not followed. The consultant pharmacist had recommended that an approved psychiatric diagnosis be documented to support the continued use of Haldol and that an informed consent form be obtained and placed in the resident's medical record. However, the medical record did not contain the required consent for Haldol until several months after the medication was ordered, and there was no documentation of a psychiatric evaluation to justify its use during that period. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The resident was admitted and re-admitted to the facility, and the Minimum Data Set (MDS) indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis. Despite this, Haldol was ordered and administered without the necessary supporting documentation, including a psychiatric evaluation and informed consent, as required by facility policy and regulatory guidelines. Interviews with facility staff, including the physician assistant, licensed vocational nurses, and the director of nursing, confirmed that the required evaluation and consent were not obtained prior to the administration of Haldol. Staff acknowledged that the proper procedures were not followed, and the documentation in the medical record was incomplete regarding the rationale for the use of the antipsychotic medication. Facility policies reviewed also emphasized the need for appropriate diagnosis, consent, and documentation when administering psychotropic medications, which were not adhered to in this case.
Unnecessary Antipsychotic Administration Without Indication or Documentation
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the administration of Haldol (an antipsychotic) without an adequate indication for use. The resident in question had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of traumatic subdural hemorrhage. Despite the absence of documented behavioral symptoms or psychosis, a new order for Haldol Decanoate 50mg IM monthly was initiated for 'aggression behavior,' but there was no supporting documentation of such behaviors in the resident’s records. Review of the resident’s medical records revealed inconsistencies and lack of clarity regarding the Haldol order. The medication was administered on at least two occasions, but the order was not consistently present on the Medication Administration Record (MAR), and there was no documented indication for use from the time the order was written through several months afterward. Interviews with facility staff, including the prescribing provider and the DON, revealed confusion about the origin of the order, with the primary physician denying knowledge of or responsibility for the prescription. Staff also confirmed that the required behavioral assessments and psychiatric evaluations were not completed prior to administration, and that the resident did not exhibit behaviors warranting antipsychotic use. Additionally, the facility’s policy required informed consent and documentation of risks, benefits, and alternatives prior to initiating psychotropic medications, especially those with black box warnings. While a consent form was eventually signed by the resident’s representative, this occurred months after the initial administration of the medication. The lack of proper documentation, absence of a clear clinical indication, and failure to follow facility policy led to the administration of an unnecessary antipsychotic medication to a resident.
Failure to Obtain Admission Orders for Blood Sugar Checks and Wound Care
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, chronic heart failure, and multiple skin impairments was readmitted to the facility without physician orders for immediate care, specifically for blood sugar checks and wound care. Upon readmission, the resident did not have orders in place for blood glucose monitoring, despite being prescribed oral diabetic medications. The lack of blood sugar checks persisted for five days, during which the resident experienced a hypoglycemic episode with a blood sugar reading of 50, requiring transfer to the hospital. Interviews with facility staff revealed that the admitting nurse did not request or clarify orders for blood sugar checks, relying solely on the hospital medication list, and was unaware of the facility's policy or standard practice for diabetic care. Additionally, the resident was admitted with multiple skin impairments, including wounds to the left foot, left heel, sacrum, and penis, but did not receive wound care orders until four days after admission. The admitting nurse documented the presence of skin impairments but did not communicate these findings to the nurse practitioner or request treatment orders. The initial nursing evaluation indicated skin issues, but no detailed assessment or wound care plan was initiated until several days later. Staff interviews confirmed that the nurse did not follow the expected process of notifying the physician about new or existing wounds upon admission. The facility lacked a clear policy for diabetic procedures or wound care at the time of the incident, and staff training on these topics was inconsistent. The failure to obtain and implement physician orders for both blood sugar monitoring and wound care at the time of admission resulted in the resident not receiving necessary care for identified health needs. This deficiency was identified as Immediate Jeopardy due to the potential for significant harm.
Failure to Provide Timely Wound Care and Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility with multiple skin impairments, including a diabetic wound to the left heel and dorsum of the foot, moisture-associated skin damage (MASD) to the sacrum, and an abrasion to the penis. Upon readmission, the admitting nurse identified skin impairments but did not document their location or measurements on the required forms and failed to communicate these findings to the nurse practitioner (NP) or request wound care orders. As a result, the resident did not have any wound care orders in place for five days following readmission, and no wound care was provided during this period. The facility's policy required notification of the physician for any new treatment needs or changes in condition, but this was not followed. Additionally, the same resident, who had a history of type 2 diabetes mellitus and was on oral diabetic medications, was readmitted without orders for blood sugar checks. The admitting nurse verified the medication list with the NP but did not request or clarify the need for blood sugar monitoring, despite the resident's diagnosis and previous history of fluctuating blood sugars. For five days, no blood sugar checks were performed, and the resident subsequently experienced an episode of hypoglycemia, with a blood sugar reading of 50, which led to a hospital transfer. The lack of blood sugar monitoring was not addressed until after the incident occurred. Interviews with facility staff, including the admitting nurse, ADON, NP, and DON, revealed a lack of communication and understanding regarding the need to obtain and clarify orders for wound care and blood sugar checks upon admission. Documentation was incomplete, and staff did not follow facility policy or professional standards of practice in assessing, documenting, and reporting the resident's condition. The facility did not have a specific policy for diabetic procedures or blood sugar checks, and staff training on these procedures was lacking at the time of the incident.
Incomplete Documentation of Treatments and Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for three residents. For one resident with a history of diabetes, COPD, and pressure injuries, the Treatment Administration Record (TAR) for March was found to have multiple unsigned sections for physician-ordered treatments, including wound care and use of a pressure-reducing mattress. Nursing staff interviewed confirmed they had provided the treatments but did not sign off on the TAR, citing reasons such as forgetting due to being busy or not understanding the significance of blank entries. Staff acknowledged that they had received training on documentation requirements but did not consistently follow facility policy. Another resident with diagnoses including diabetes, heart failure, and skin integrity issues had incomplete documentation on both the TAR and Medication Administration Record (MAR). Several physician-ordered treatments for wounds and pressure reduction were not signed off on the TAR for various shifts, and a blood sugar check and insulin administration were not documented on the MAR. Nursing staff responsible for these omissions stated they either forgot to document, did not see the order, or were unsure of the policy. In one instance, a nurse failed to document a resident's refusal of a blood sugar check and insulin, which should have been coded appropriately on the MAR. A third resident, also with diabetes and severe cognitive impairment, had incomplete documentation on the MAR for sliding scale insulin orders. The MAR lacked signatures and blood glucose documentation for scheduled times, and staff could not recall the specifics of care provided on those dates. Interviews with nursing and administrative staff confirmed that the required documentation was missing and that staff had not followed the facility's documentation policy, despite recent training. The facility's policy requires all assessments, observations, and services to be accurately and timely documented in the resident's medical record, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #1's care plan did not include his wound or the physician-ordered wound care, despite having a surgical incision on his right plantar foot that required daily treatment. This omission was confirmed during a review of Resident #1's care plan, which lacked any mention of his wound care needs. For Resident #2, the care plan did not address her diet or the need for crushed medications, even though she had a diagnosis of dysphagia and a modified barium swallow study recommended a pureed diet and crushed medications to mitigate choking risks. Similarly, Resident #3's care plan failed to include his diet and the need for crushed medications, despite having physician orders for a pureed diet and a history of orders for crushed medications. Resident #4's care plan also lacked details about her diet and the need for crushed medications, although her medical records indicated these requirements. Interviews with facility staff, including MDS C and the DON, revealed that the care plans were not updated to reflect these critical needs due to oversight and staffing issues. MDS C and the DON acknowledged the importance of including such information in care plans to ensure appropriate interventions and goals for residents. However, the care plans for these residents were incomplete, potentially impacting their care and safety.
Failure to Obtain Orders for Crushed Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, specifically in obtaining and inputting orders for crushed medications. Resident #3, a male with multiple diagnoses including metabolic encephalopathy and acute respiratory failure, was on a mechanically altered diet but did not have an active order for crushed medications. Although there was a previous order allowing for medications to be crushed as needed, it was discontinued, and no new order was in place until after surveyor intervention. Similarly, Resident #4, a female with dysphagia and other conditions, also lacked an order for crushed medications despite recommendations from a modified barium swallow study indicating a choking risk. Interviews with staff revealed a reliance on residents' diets to determine the need for crushed medications, rather than ensuring proper orders were in place. Medication aides and the Assistant Director of Nursing (ADON) acknowledged the absence of orders for crushed medications for both residents, despite the facility's policy requiring such orders. The staff admitted to using nursing judgment based on diet rather than formal orders, which led to inconsistencies in medication administration. The Director of Nursing (DON) confirmed that orders for crushed medications were necessary according to facility policy and acknowledged the oversight in not having these orders in place for Residents #3 and #4. The DON stated that the facility had been relying on diet information to guide medication administration, which had not resulted in any negative effects, but recognized the importance of having formal orders to prevent potential risks such as choking or aspiration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for four residents. Resident #12 was found with four unidentified pills and two capsules in a medication cup on his overbed table, which he had not taken. The Medication Aide left Resident #12's medications on his bedside table and documented that the medications had been administered, despite the resident not taking them. Interviews revealed that the Med Aide did not follow the proper procedure of staying with the resident until the medication was taken, leading to a discrepancy in the medication administration record (MAR). For Residents #23, #35, and #63, there were instances where medications were not signed off on the MAR on specific dates. Resident #23 had five medications not signed off, Resident #35 had two, and Resident #63 had three. Interviews with staff indicated that personal issues and overwhelming situations, such as a high number of visitors, contributed to the failure to document medication administration properly. This lack of documentation could potentially lead to residents receiving double doses of medication, although no negative outcomes were reported. The facility's policy on medication administration requires that medications be administered by licensed nurses or authorized staff, with proper documentation on the MAR. The failure to adhere to these procedures, as evidenced by the missing signatures and improper medication handling, highlights a significant deficiency in the facility's pharmaceutical services. The DON acknowledged the oversight in reviewing daily reports that would have flagged the missing signatures, indicating a lapse in the facility's internal monitoring processes.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences, specifically regarding the accessibility of call lights. Two residents, both with significant mobility impairments and at risk for falls, were found to have their call lights out of reach. Resident #90, who has muscle weakness and hemiparesis following a stroke, was observed with her call light on the floor next to her bed. Similarly, Resident #98, who has muscle weakness and a history of falls, had her call light on the floor behind a nightstand. Both residents require assistance with personal care and rely on the call light system to request help. Interviews with staff, including a nursing assistant and the Assistant Director of Nursing (ADON), confirmed that call lights should be within reach of residents at all times to ensure they can call for assistance when needed. The staff acknowledged the importance of this practice and admitted that the call lights were not properly secured in these instances. The facility's policy on call light accessibility emphasizes the need for staff to ensure call lights are within reach and secure, yet this was not adhered to, leading to the deficiency.
Failure to Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's right to formulate advance directives was honored, as evidenced by the absence of the resident's code status in the facility's records. The resident, who had a moderately impaired cognitive status with a BIMS score of 10, was admitted with several medical conditions, including Nontraumatic Acute Subdural Hemorrhage, Type 2 Diabetes Mellitus, Hemiplegia, and Essential Primary Hypertension. Despite these conditions, the facility did not have an active physician's order for the resident's code status, which is crucial for honoring the resident's end-of-life wishes. Interviews with facility staff revealed a lack of clarity and consistency in handling advance directives. LVN A and the DON both indicated that without the DNR paperwork, residents were defaulted to full code status, potentially leading to unwanted resuscitative measures. The Social Services staff mentioned discussing advance directives during admission but acknowledged a delay in completing the documentation. The admission nurse, LVN H, admitted to possibly forgetting to enter the code status, highlighting a gap in the facility's process for ensuring residents' advance directives are accurately recorded and respected.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which included necessary instructions for effective and person-centered care. Specifically, the advance directive section of the baseline care plan was not completed for the resident, who had a moderately impaired cognition with a BIMS score of 10. The resident's medical conditions included Nontraumatic Acute Subdural Hemorrhage, Type 2 Diabetes Mellitus without Complications, Hemiplegia, and Essential Primary Hypertension. The absence of advance directive information in the resident's electronic face sheet and physician order summary report meant there was no active physician's order for code status, leaving the resident's end-of-life wishes unaddressed. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for entering and managing code status information. An LVN was unable to find the code status in the resident's electronic chart and stated that without the necessary documentation, the resident would be considered full code by default. The MDS coordinator indicated that nurses open the initial baseline care plan, while social services are responsible for completing the code status. However, the social services staff member believed she had five days to complete the advance directives, contrary to the facility's policy requiring completion within 48 hours. This miscommunication and misunderstanding of responsibilities contributed to the deficiency in the resident's baseline care plan.
Failure to Update Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #63, who was at high risk of elopement. Despite being admitted to the secured unit due to this risk, the resident's care plan did not reflect this critical information. The care plan, dated 05/29/2024, was supposed to include measurable objectives and timeframes to meet the resident's needs, as identified in the comprehensive assessment. However, it lacked the necessary details about the resident's placement in the secured unit, which was a significant oversight given her diagnosis of Alzheimer's disease and severely impaired cognition. Interviews with the MDS-LVN and the DON revealed that the omission was an oversight, as the MDS-LVN admitted to forgetting to update the care plan to reflect the resident's housing in the secured unit. Both staff members acknowledged that the care plan should have included this information, although they noted that there were no negative outcomes for the resident due to this omission. The facility's policy mandates that care plans be comprehensive and person-centered, incorporating the resident's strengths, needs, and preferences, but this was not adhered to in this instance.
Inadequate Catheter Care Leads to Infection Control Issue
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter, which could lead to an increased risk of urinary tract infections. The resident, an elderly male with severe cognitive impairment and medical conditions including benign prostatic hyperplasia and acute kidney failure, was observed with his catheter tubing touching the floor. This observation was made despite the care plan specifying that the catheter bag and tubing should be positioned below the bladder level and away from the door entrance. Interviews with facility staff, including an LVN and the DON, revealed that the responsibility for catheter care was assigned to the floor nurse. The LVN acknowledged that the catheter tubing should not be on the floor and suggested using a sheath to prevent infection control issues. The DON confirmed that catheter tubing on the ground was an infection control issue and mentioned ongoing in-services for catheter care. However, the facility failed to provide the requested policies on catheter care or infection control before the survey exit.
Deficiency in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide respiratory care according to professional standards for two residents who required oxygen therapy. Resident #258, a female with acute respiratory failure, chronic pulmonary edema, pneumonia, and acute systolic heart failure, was observed to have her oxygen administered at 3.5 liters per minute (Lpm) instead of the physician-ordered 2 Lpm. This discrepancy was noted during an observation on June 24, 2024, when the Director of Nursing (DON) checked the oxygen machine and found it set incorrectly. The DON confirmed that the nurses are trained to set the ball meter to the middle of the ball and are responsible for checking the oxygen machine at the beginning and throughout their shifts. Similarly, Resident #260, a female with metabolic encephalopathy, acute respiratory failure with hypoxia, chronic pulmonary edema, and acute systolic heart failure, was found to have her oxygen set at 2.5 Lpm instead of the ordered 3.0 Lpm. This was observed on June 24, 2024, with the ball meter set to the top of the ball rather than the middle. An interview with LVN A revealed that nurses are responsible for setting the oxygen machines correctly and are trained to ensure the middle of the ball is level with the prescribed number. LVN A also mentioned that further training would likely occur following the survey. The facility's Medication Administration policy, dated October 24, 2022, states that medications, including oxygen, are to be administered by licensed nurses as ordered by the physician and in accordance with professional standards. The policy emphasizes the importance of reviewing the Medication Administration Record (MAR) to ensure correct administration. Despite these guidelines, the facility's failure to adhere to the prescribed oxygen levels for these residents represents a deficiency in providing safe and appropriate respiratory care.
Failure to Accurately Code Falls in MDS
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their fall incidents, which were not properly coded in the Minimum Data Set (MDS). Resident #1, who had a history of dementia, lack of coordination, Parkinson's disease, and unsteadiness, experienced an unwitnessed fall. Despite this, the fall was not recorded in the resident's annual MDS, which could lead to improper care and services. The MDS Nurse acknowledged the oversight, indicating that the fall should have been coded to ensure the resident received appropriate care. Similarly, Resident #2, diagnosed with Alzheimer's disease, had two falls that were not captured in the quarterly MDS. The resident had a witnessed fall resulting in a minor skin tear and another unwitnessed fall. Despite these incidents being documented in the care plan and interventions being implemented, the falls were not reflected in the MDS. The MDS Nurse admitted the error, suggesting it was an oversight, and the Director of Nursing (DON) confirmed that the falls were care planned but not coded in the MDS. The failure to accurately code these falls in the MDS could potentially place residents at risk of receiving incorrect care. The facility's interdisciplinary team, including the DON and MDS Nurse, is responsible for ensuring the accuracy of MDS assessments. However, the oversight in coding these falls indicates a lapse in the assessment process, which could impact the residents' physical, mental, and psychosocial well-being.
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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