Cascades At Senior Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Arthur, Texas.
- Location
- 8825 Lamplighter Ln, Port Arthur, Texas 77642
- CMS Provider Number
- 675541
- Inspections on file
- 48
- Latest survey
- February 21, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Cascades At Senior Rehab during CMS and state inspections, most recent first.
A resident with a suprapubic catheter and multiple comorbidities was on Enhanced Barrier Precautions (EBP), with orders and a care plan requiring staff to wear gown and gloves for high-contact care and to follow infection control procedures. A CNA entered the room without a gown, donned gloves without hand hygiene, handled and emptied the catheter bag that had been on the floor, then returned it to the floor and later placed it on the resident’s bed without sanitizing it or changing the bag or linens. The CNA used the same pair of gloves for incontinent care and dressing and did not perform hand hygiene after care, contrary to facility policy and stated expectations of the charge nurse and DON regarding hand hygiene, PPE use, and proper catheter bag handling.
A resident with severe cognitive impairment and an indwelling suprapubic catheter had a documented physician order for a 16 FR/30 ml catheter with statlock securement, but surveyors observed an unsecured 18 FR/30 ml catheter in place and no leg securement device. MAR review showed an LVN had recorded changing the catheter to a 16 FR/30 ml, yet the catheter present did not match the order. Interviews with an LVN, the ADON, and the DON revealed they were unaware the catheter was unsecured and the wrong size was in use, despite facility policy requiring catheter securement and nursing responsibility to verify and correctly implement catheter orders.
A resident with schizoaffective disorder, post-stroke aphasia and dysphagia, anxiety, seizures, and severely impaired cognition had a documented history of physical aggression and required extensive assistance with ADLs and mobility. Two separate incidents occurred in which this nonverbal resident hit another resident, once in a hallway and once involving a roommate, with staff separating the residents, assessing for injury, initiating short-term behavior monitoring, and notifying appropriate authorities. Despite these events and discussion of the incidents in morning meetings, the IDT did not revise the comprehensive care plan to reflect the new resident-to-resident incidents or add specific updated interventions, and no new interventions had been added to the care plan for an extended period. The MDS coordinator later acknowledged forgetting to update the care plan, and leadership confirmed there was no facility-specific policy for care plan revision beyond following the RAI Manual.
A resident with neuromuscular bladder dysfunction and severe cognitive impairment was found with an unsecured Foley catheter, despite physician orders and facility policy requiring securement. Nursing staff acknowledged responsibility for ensuring catheter securement but failed to do so, resulting in noncompliance with established protocols.
A nurse left a medication cart unlocked and unattended in a hallway, making medications accessible to unauthorized individuals. The cart contained various medications, including controlled substances, and was out of the nurse's line of sight. Facility policy and staff interviews confirmed that medication carts are required to be locked and supervised at all times.
Two shower rooms were found with soiled equipment, including shower chairs with brown and black substances and a shower bed with a thick black coating under the cushion. Staff interviews revealed that cleaning protocols requiring aides to clean equipment before and after each use were not consistently followed, and equipment was not always cleaned according to facility policy.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unsupervised, containing various medications and supplies labeled as 'keep out of reach of children.' Additionally, a nurse cart contained loose pills and an opened Basaglar insulin pen without a date of opening. Staff interviews confirmed that these practices were against facility policy, which requires all medications to be securely stored and properly labeled.
Multiple residents experienced verbal and physical abuse from other residents, including incidents where a resident with dementia was slapped, a resident with anxiety was verbally abused, a resident with bipolar disorder was physically shaken, and a resident was struck after a wheelchair collision. Despite care plans addressing behavioral risks and interventions, these abusive events were not prevented, indicating a failure to protect residents from abuse as required.
Two residents did not receive care as ordered by their physicians: one did not receive newly prescribed Depakote for mood stabilization due to missed doses and lack of documentation, while another did not have a urine specimen collected for a UTI Panel before starting antibiotics, as required. These failures were due to lapses in staff communication, documentation, and timely execution of orders.
A resident with severe cognitive impairment was incorrectly documented as having side rails or restraints on the MDS assessment, despite no such devices being present or ordered. Staff interviews and record reviews confirmed the error was due to an accidental marking by the MDS Nurse, and the resident's care plan and actual care did not include side rails or restraints.
A resident with a history of mental illness and psychotropic medication use was readmitted from a mental health hospital, but the required PASRR Level 1 screening was not properly submitted, and no Level II evaluation was completed. The MDS nurse responsible for PASRR forms acknowledged the oversight, and the DON confirmed the lapse in procedure, resulting in missing documentation and evaluation for the resident.
A resident with multiple medical conditions did not receive the prescribed dose of vitamin C due to a medication administration error by an LVN, who gave only one tablet instead of the ordered two. Additionally, three aspart insulin pens remained on a medication cart beyond the recommended 28-day use period, as nursing staff failed to remove them as required. Facility policies for medication administration and removal of expired drugs were not followed, leading to these deficiencies.
A resident with hypertension received Metoprolol and Hydralazine despite blood pressure and heart rate readings that were outside the physician-ordered parameters. Facility staff, including an LVN, confirmed the medications were given in error, and the DON and administrator stated that medications should be administered according to orders. Facility policy required adherence to prescriber instructions.
The facility did not notify physicians when two residents experienced missed or delayed treatments. One resident did not have a urine specimen collected for a UTI panel before starting antibiotics, and the physician was not informed. Another resident missed two doses of a newly prescribed medication for mood, and the physician was not notified of the missed doses. Nursing and administrative staff confirmed these lapses in communication.
A resident with a tracheostomy did not receive a scheduled outer cannula change as ordered by the physician, and there was no documentation of the procedure being performed on the medication administration record. Interviews with the ADON, DON, and the LVN responsible confirmed the lack of documentation and indicated the procedure was not completed as required by facility policy.
A resident with multiple health conditions, including morbid obesity and muscle weakness, who required two-person assistance for bed mobility, was left unsupervised by a single CNA during incontinent care. This resulted in the resident sliding off the bed and sustaining an acute distal femur fracture, requiring hospitalization and surgery. Documentation and staff interviews confirmed that the need for two-person assistance was clearly indicated in the care plan and Kardex, but the protocol was not followed.
A resident with a history of mental health and substance use disorders reported to the admission coordinator that a CNA was verbally and physically aggressive and prevented him from calling the police. The admission coordinator did not immediately report the allegation to the abuse coordinator or administrator, resulting in a delay in notifying authorities beyond the required two-hour timeframe. Staff interviews confirmed the delay, and facility policy requiring immediate reporting was not followed.
Two residents received wound care without proper adherence to enhanced barrier precautions, including failures by nursing staff to wear required PPE, perform hand hygiene at appropriate times, and handle wound care supplies according to infection control protocols.
A resident with a history of schizophrenia and aggressive behavior repeatedly assaulted other residents, resulting in injuries. The facility failed to implement adequate supervision or specific interventions to prevent further incidents, despite being aware of the resident's tendencies. Staff interviews revealed a lack of awareness of monitoring requirements, contributing to the failure to protect residents from harm.
A facility failed to investigate and report an incident where a resident with severe cognitive impairment slapped another resident, causing injury. Despite the incident being reported to administration and medical staff, no investigation report was submitted to the State Survey Agency within the required timeframe, potentially placing residents at risk of further abuse.
The facility failed to notify the physician of changes in condition for two residents. One resident had multiple instances of elevated blood pressure, and another had her medication held due to low pulse readings. In both cases, the physician was not consulted, contrary to facility policy.
The facility failed to protect two residents from abuse. A resident with schizoaffective disorder was verbally abused by a CNA, who unplugged the facility phone and called her derogatory names. Another resident with Alzheimer's was physically abused by his roommate, who grabbed his arm, causing redness. Both incidents were not promptly reported to the appropriate authorities, violating the facility's policies.
The facility failed to implement policies to prevent abuse, neglect, and exploitation for three residents. One resident experienced verbal abuse from a CNA, another was physically aggressed by a roommate, and a third resident with a history of aggression was involved in the incident. Reporting of these incidents was delayed, contrary to facility policy.
The facility failed to report alleged abuse incidents involving three residents to the administrator and State Agency within the required 2-hour period. Incidents included verbal abuse by a CNA and physical altercations between residents. The delays in reporting violated facility policies and state regulations.
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in documenting special treatments and procedures. One resident with quadriplegia and tracheotomy status did not have her tracheostomy care accurately reflected in her MDS assessment, while another resident with chronic kidney disease and dependence on renal dialysis did not have his dialysis treatments documented. The deficiencies were attributed to oversight and lack of a double-check system.
The facility failed to trim the fingernails of a resident with severe cognitive impairment and contractures, despite care plans and policies requiring regular nail maintenance. Staff acknowledged the oversight, and the resident expressed a desire to have his nails cut.
A resident with hemiplegia/hemiparesis and stroke did not receive the ordered resting hand splint to treat and correct contracture. Observations and staff interviews revealed that the splint was not applied as required, and the resident's care plan and TARs did not reflect the necessary interventions. This failure placed the resident at risk of further contractures and decreased range of motion.
A resident with multiple health conditions, including atrial fibrillation and morbid obesity, was observed receiving oxygen at 3 liters per minute instead of the prescribed 2 liters. Despite the physician's order and the facility's Oxygen Administration policy, staff failed to administer the correct dosage, potentially risking the resident's health.
A facility failed to document BP and HR before administering metoprolol tartrate to a resident with hypertension, despite prescribed parameters. Staff interviews and record reviews revealed an oversight in the system and failure to trigger necessary documentation, leading to a significant deficiency in medication administration procedures.
A resident with hypertension and heart failure was administered metoprolol tartrate despite having a pulse below the prescribed parameters on three occasions. The facility's policy on medication therapy was not followed, leading to the administration of the medication contrary to the physician's orders.
The facility failed to employ a qualified social worker on a full-time basis for approximately six months, relying instead on a part-time social worker who worked as needed and on some weekends. Despite efforts to hire a full-time social worker, the position remained unfilled, which was confirmed through interviews with HR staff, the part-time social worker, and the Administrator. The facility has a licensed capacity of 199 beds, necessitating a full-time social worker.
The facility failed to provide mandatory QAPI training to eight staff members, including the Dietary Supervisor, ADON, LVNs, Laundry Supervisor, and CNAs, as required. Record reviews and interviews revealed that these staff members had no documented QAPI training, despite the Administrator's expectation that such training was included in the computerized training system and in-service orientation.
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for four residents. This included missing documentation for wound care and weekly skin assessments on specific dates, leading to incomplete or inaccurate records and inadequate care.
The facility failed to provide necessary behavioral health services to a resident after his return from a behavioral health hospital. Despite the need for follow-up psychiatry services, no psychiatric assessment or behavior monitoring was conducted. The resident had been involved in an altercation and exhibited aggressive behavior, but the facility did not update his care plan or ensure he received the required services.
A resident who required two-person assistance for bed mobility fell and sustained a scalp hematoma when a CNA provided incontinent care alone, contrary to the care plan. The CNA did not check the Kardex or request help from available staff, leading to the incident.
Failure to Follow Enhanced Barrier Precautions and Catheter Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP) related to a suprapubic catheter. The resident was an adult male with hemiplegia and hemiparesis of the left non-dominant side, COPD, a history of UTI, and a bulbar urethral stricture, and had an indwelling catheter. His active orders and care plan required staff to use gown and gloves before room entry and during high-contact care activities, including catheter care, dressing, bathing, hygiene, and toileting, and to follow EBP protocols to prevent infection. During an observation, a CNA entered the resident’s room without wearing a gown or gloves, despite the resident being on EBP. The resident’s suprapubic catheter bag was on the floor near the bed. The CNA donned gloves without performing hand hygiene, picked the catheter bag up from the floor, emptied 580 ml of urine into a urinal, and then placed the catheter bag back on the floor. After discarding the used gloves, the CNA applied a new pair without hand hygiene and proceeded to provide incontinent care and dress the resident using the same pair of gloves. The CNA then picked the catheter bag from the floor and placed it on the resident’s bed to dress him, without sanitizing the bag, changing the bag, or changing the bed linens, and did not perform hand hygiene after completing care. In interviews, the CNA acknowledged she should have worn a gown, kept the catheter bag off the floor on a fixed structure below bladder level, and performed hand hygiene between glove changes and before handling the catheter bag. The charge nurse and DON stated their expectations that staff perform hand hygiene before, between, and after glove changes, keep catheter bags off the floor, and wear gowns and gloves for residents on EBP, consistent with facility policies on catheter care and the infection prevention and control program.
Failure to Secure Suprapubic Catheter and Follow Ordered Catheter Size
Penalty
Summary
Surveyors identified that a resident with neuromuscular bladder dysfunction, quadriplegia, aphasia, tracheostomy, and severe cognitive impairment (BIMS score of 0) did not receive appropriate treatment and services related to an indwelling suprapubic catheter. The resident’s care plan documented an indwelling 18 FR suprapubic catheter with an intervention to ensure a statlock was in place to secure the Foley tubing to prevent injury. The physician’s order summary, however, directed that a 16 FR/30 ml suprapubic catheter be exchanged every four weeks and as needed, and that the suprapubic catheter be secured with a statlock. Record review of the MAR showed that on a specified date at 2:20 a.m., an LVN changed the resident’s suprapubic catheter and documented insertion of a 16 FR/30 ml catheter. During observation later that morning, surveyors noted the resident in bed with the suprapubic catheter unsecured and without a statlock or other leg securement device in place. The catheter in place was labeled 18 FR/30 ml, which did not match the physician’s order for a 16 FR catheter. A subsequent observation confirmed that both 16 FR and 18 FR catheters were available in the facility’s supply room. In interviews, an LVN stated the resident had an order for a 16 FR suprapubic catheter since a specified date but currently had an 18 FR catheter in place, and acknowledged she was unaware the catheter was unsecured and that nurses were responsible for verifying catheter size and securement at the start of their shifts. The ADON confirmed the order for a 16 FR suprapubic catheter, acknowledged that an 18 FR catheter had been placed by an LVN, and stated he was not aware the wrong size catheter was in place. The DON also stated she was not aware the catheter was unsecured or that the wrong size (18 FR instead of 16 FR) had been used, and affirmed that nurses were responsible for verifying and correctly implementing physician orders, including inserting the correct catheter size and securing it. Facility policy on urinary catheter care required that catheters remain secured with a securement device to reduce friction and movement at the insertion site.
Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after significant behavioral incidents, as required. The resident was a female with schizoaffective disorder, cerebral infarction with resulting aphasia and dysphagia, anxiety disorder, seizures, and severely impaired cognition (BIMS score of 00). Her quarterly MDS dated 06/22/2025 showed she was sometimes able to make herself understood, usually understood others, and required moderate to maximum assistance with most ADLs and mobility, using a manual wheelchair with supervision or touching assistance. Her care plan, last revised on 11/03/2025, documented a history of physical aggression toward staff and other residents and included general interventions such as PRN medications, anticipating needs, communication techniques, behavior monitoring, psychiatric consults as indicated, and notification of appropriate authorities. Despite this history and the presence of two documented resident-to-resident incidents, the care plan was not updated to reflect these specific events or any new interventions. On 07/18/2025, progress notes and an incident report authored by an LVN documented that the resident, while in a wheelchair in the hallway, grabbed another resident by the hands and slapped the other resident on the left side of the face. The CNA who witnessed the event immediately separated the residents, and the LVN completed a head-to-toe assessment, pain assessment, and vital signs, with no injuries or pain noted. A provider investigation report dated 07/22/2025 confirmed that the resident hit another resident on the left side of the face/neck, that both residents had no injuries, and that behavioral monitoring was initiated for 72 hours. However, the comprehensive care plan showed no revisions or added interventions related to this incident. A second incident occurred on 08/16/2025, documented in progress notes and an incident report by another LVN. A CNA reported that the resident hit her roommate twice in the chest after an interaction involving the roommate’s bed linens. The residents were separated, both were assessed with no injuries noted, and the resident denied pain by shaking her head. A provider investigation report dated 08/16/2025 confirmed that the resident hit another resident on the chest, that both residents had no injuries, and that behavioral monitoring was again initiated for 72 hours. Interviews with the LVNs indicated that staff viewed the resident’s hitting/patting as a way to gain attention due to her being nonverbal, and that they followed facility protocols for assessment, monitoring, separation, and notification of authorities. Nonetheless, review of the care plan showed no interventions added since 06/17/2024 and no updates to reflect these two resident-to-resident incidents. Interviews with the MDS Coordinator, DON, and Administrator further clarified the inaction that led to the deficiency. The MDS Coordinator stated that incidents and allegations were discussed in morning meetings and that she recalled discussing the July and August incidents involving this resident, believing at the time that the care plan had been updated. She acknowledged that the care plan should have been revised to reflect the resident’s current needs and the interventions used, including monitoring, authority notification, and communication techniques, and admitted she had forgotten to update the care plan. The DON stated that all incidents were discussed in morning meetings, that the MDS Coordinator was responsible for revising care plans, and that new interventions should be added for recurrent resident-to-resident altercations; she did not know why the care plan had not been updated. The Administrator stated that the MDS Coordinator and DON were responsible for ensuring care plans were updated and recognized that failure to revise care plans could result in residents not receiving needed care. Both the DON and MDS Coordinator reported that the facility had no specific policy for care plan updating or revision and that they followed the RAI Manual, which states that significant changes requiring interdisciplinary review and/or care plan revision include major declines or improvements that are not self-limiting and affect more than one area of health status. The combined record review and staff interviews demonstrated that, although the resident experienced at least two documented resident-to-resident physical contact incidents and was placed on behavioral monitoring each time, the interdisciplinary team did not revise the comprehensive care plan to incorporate these events or any specific, updated interventions. The care plan remained unchanged with no new interventions added since 06/17/2024, despite the resident’s ongoing behavioral issues and the subsequent incidents. This failure to update the care plan after each assessment and incident constituted the cited deficiency in care planning for this resident.
Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency occurred when a male resident with neuromuscular dysfunction of the bladder, who was severely cognitively impaired and required assistance with all activities of daily living, was observed without his Foley catheter being secured to his leg as required. The resident's care plan and physician orders specified that the catheter should be secured with a leg strap and monitored twice daily to prevent catheter-related trauma. On the date of observation, no securement device was present, and the Foley catheter was not attached to the resident's leg. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that it was the responsibility of the nursing staff to ensure the catheter was properly secured according to facility policy and physician orders. The LVN admitted to not checking the securement device at the start of her shift and was unaware that it was missing. Facility policy, revised in August 2022, also required that urinary catheters remain secured to prevent complications. The failure to secure the catheter as ordered and per policy constituted the deficiency.
Medication Cart Left Unlocked and Unattended by Nurse
Penalty
Summary
A deficiency occurred when a nurse failed to secure the Hall 300 medication cart, leaving it unlocked and unattended for approximately five minutes in a hallway. During this time, the cart was positioned with its drawers facing the hallway and the lock mechanism disengaged, making medications accessible to unauthorized individuals. The nurse responsible for the cart admitted to being two rooms away and out of sight of the cart, acknowledging that she forgot to lock it before leaving. Observations revealed that the cart contained glucometers, over-the-counter medications, vitamins, minerals, eye drops, and a locked compartment with controlled substances and resident-specific medication packets. Interviews with the nurse, DON, and Administrator confirmed that facility policy requires medication carts to be locked and within the nurse's line of sight when not in use. The nurse stated she had been trained to keep the cart locked and recognized the risk of leaving it unsecured. The DON and Administrator reiterated expectations that all nursing staff are responsible for securing medication carts to prevent unauthorized access, in accordance with facility policy and procedures.
Failure to Maintain Clean and Safe Shower Equipment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of four shower rooms reviewed. In Hall 300, two shower chairs were observed to be soiled with brown and black substances on the seat, under the seats, and on the frame. Additionally, a section of the shower wall and baseboard was soiled with a black substance. Staff interviews revealed that shower chairs were expected to be cleaned before and after each use by the aides, with cleaning supplies provided and stored securely. However, the presence of soiling indicated that these cleaning protocols were not consistently followed. In Hall 400, a shower bed was found with a thick black substance coating the full length of the white plastic stretcher part under the cushion. Staff acknowledged that the bed needed cleaning, and one CNA reported that she had last used the bed a couple of weeks prior, cleaning only the surface and not removing the cushion to clean underneath. Review of the facility's policy confirmed that reusable resident-care equipment should be cleaned and disinfected between uses and according to manufacturer instructions, but these procedures were not adhered to, resulting in unclean equipment in the shower rooms.
Failure to Secure Medication Carts and Properly Label Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely and in accordance with state and federal regulations. On multiple occasions, the medication treatment cart was found unlocked and unsupervised at the main nurse station, containing various medications and treatment supplies labeled as 'keep out of reach of children.' Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the cart should always be locked and that the key was kept in the medication room. Despite this, the cart was repeatedly left unsecured, and staff were unable to identify who last used it. Further inspection of the Hall 400 Nurse Cart revealed four loose pills and an opened Basaglar insulin pen that was not labeled with the date it was first opened. The LVN responsible for the cart acknowledged that staff are expected to check their carts daily for loose pills and ensure all medications are properly labeled and stored in original pharmacy packaging. The DON confirmed that nurses are responsible for keeping medication carts clean, free of loose pills, and for labeling insulin with the date opened. A review of the facility's policy on medication labeling and storage indicated that medications must be stored in their original containers, and all compartments containing medications must be locked when not in use. The policy also stated that only the issuing pharmacy is authorized to transfer medications between containers, and that nursing staff are responsible for maintaining medication storage areas in a clean and safe manner. These observations and interviews demonstrated that the facility did not consistently follow its own policies or regulatory requirements regarding medication security and labeling.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from verbal and physical abuse by other residents, as evidenced by four separate incidents involving different individuals. In one case, a female resident with dementia and severely impaired cognition was slapped in the face by another resident with schizophrenia and vascular dementia while both were in wheelchairs. The care plan for the victim included interventions to assess and document claims of aggression and to separate her from others to ensure safety, but the incident still occurred. The aggressor had a care plan addressing behavioral issues related to schizophrenia, with interventions to protect others and monitor behaviors, yet the physical abuse was not prevented. Another incident involved a female resident with anxiety and depression who was verbally abused by a male resident with a history of traumatic brain injury and behavioral syndromes. The male resident cursed at her and made a distressing comment about her deceased daughter. The care plan for the aggressor acknowledged his potential for verbal and physical aggression and included monitoring and separating him from others, but he was still able to verbally abuse another resident. The victim reported feeling afraid at the time of the incident, although she later stated she felt safe after the aggressor apologized. Additional incidents included a female resident with bipolar disorder being physically grabbed and shaken by the same male resident with behavioral issues, despite staff being present and attempting to intervene. In another case, a female resident who often propelled her wheelchair backward accidentally made contact with a male resident, who then struck her on the arm. Both residents had care plans addressing their behaviors and mobility, but the physical altercation still occurred. These events demonstrate that the facility did not effectively implement measures to prevent abuse between residents, as required by their own policies and care plans.
Failure to Follow Physician Orders for Medication Administration and Laboratory Testing
Penalty
Summary
The facility failed to ensure that services provided or arranged met professional standards of quality for two residents in relation to following physician orders. For one resident with a history of traumatic brain injury, bipolar disorder, anxiety disorder, major depressive disorder, and behavioral syndromes, there was a new order for Depakote 250mg twice daily for mood stabilization following discharge from a psychiatric hospital. The medication was not administered as ordered; the resident did not receive the evening dose on the day of return or the morning dose the following day. Staff interviews revealed confusion regarding the medication order's start date, lack of documentation on the MAR, and a failure to notify the physician of the missed dose. The medication was available in the emergency supply, but it was not given, and the pharmacy had not received a request to fill the medication prior to staff inquiry. For another resident with diagnoses including pyelonephritis, head injuries, and quadriplegia, the physician ordered a UTI Panel to be obtained prior to starting antibiotics. The order was documented, but there was no evidence in the medical record or laboratory results that the urine specimen was collected before the initiation of antibiotics. Staff interviews confirmed that the UTI Panel was not obtained as ordered, and the physician was notified after the fact. The specimen was eventually collected and processed several days later, but not in accordance with the original physician order. In both cases, the facility did not follow physician orders as outlined in the residents' comprehensive care plans. There was a lack of documentation, communication, and timely action by nursing staff, resulting in the failure to administer medication and obtain required laboratory specimens as prescribed.
Inaccurate MDS Assessment for Restraint/Side Rail Use
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, resulting in an incorrect indication that the resident had a restraint or side rail in use. The resident in question was a female with diagnoses of dementia and bipolar disorder, who was severely cognitively impaired and required supervision for mobility. Review of her care plans, physician's orders, and medication administration records showed no documentation or prescription for side rails or restraints. Observations confirmed that the resident did not have side rails or restraints on her bed. Interviews with facility staff, including the LVN, MDS Nurse, DON, and Administrator, consistently confirmed that the resident did not have side rails or restraints. The MDS Nurse acknowledged that the error was due to accidentally marking the side rail box on the MDS assessment. The facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) guidelines. The inaccurate MDS assessment was not reflected in the resident's care plan or actual care provided.
Failure to Submit PASRR Screening After Resident Readmission
Penalty
Summary
The facility failed to accurately submit a PASRR Level 1 (PL1) screening for a resident who was readmitted from a mental health hospital with diagnoses including anxiety, schizophrenia, and depression. Despite the resident's history of mental illness and use of psychotropic medications, there was no evidence of a PASRR Level II screening or Form 1012 in the clinical record following the readmission. The resident's PL1 form indicated a positive result for mental illness, but the required follow-up evaluation by the local mental health authority was not completed. Interviews with facility staff revealed that the MDS nurse, who was responsible for PASRR forms, acknowledged overlooking the transmission of the PL1 form upon the resident's readmission. The DON confirmed that the MDS nurse had been trained on PASRR procedures but failed to complete the necessary steps, resulting in the absence of required documentation and evaluation for the resident after readmission.
Failure to Administer Medications as Ordered and Remove Expired Insulin Pens
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for residents. Specifically, a male resident with multiple diagnoses, including protein-calorie malnutrition, diabetes, and cerebrovascular disease, did not receive his prescribed dose of vitamin C as ordered by his physician. The physician's order required two 500 mg tablets of ascorbic acid to be administered once daily, but only one tablet was given on at least one occasion. The nurse responsible acknowledged the error, stating she missed the correct dosage during medication administration. Additionally, the facility did not ensure the timely removal of expired aspart insulin pens from a medication cart. Three insulin pens were found in use beyond the recommended 28-day period after opening, with one pen expired for 31 days, another for 9 days, and a third for 5 days. Nursing staff were expected to check medication carts daily for expired medications, but these insulin pens were overlooked and remained accessible for use. Interviews with nursing staff and the DON confirmed that the facility's procedures required adherence to prescriber orders and timely removal of expired medications. The facility's policies outlined the need for safe and timely medication administration, including verifying the correct dosage and removing outdated medications. However, these procedures were not followed, resulting in medication errors and the presence of expired insulin pens on the medication cart.
Failure to Hold Antihypertensive Medications per Prescribed Parameters
Penalty
Summary
A deficiency occurred when a cognitively intact female resident with a diagnosis of hypertension received blood pressure medications outside of the prescribed parameters. The resident's physician orders specified that Metoprolol tartrate 25 mg should be held if systolic blood pressure (SBP) was below 100, diastolic blood pressure (DBP) below 60, or heart rate (HR) below 60, and Hydralazine HCL 25 mg should be held if SBP was below 110 or DBP below 60. Despite these clear instructions, medication administration records showed that the resident received Metoprolol and Hydralazine on multiple occasions when her blood pressure and/or heart rate were outside the specified parameters. Interviews with facility staff confirmed that the medications were administered in error. The DON stated that medications should be given according to physician orders, and the administrator expected staff to monitor for accuracy. The nurse involved acknowledged the oversight, attributing it to not paying sufficient attention during medication administration, despite having been educated on the importance of following medication parameters. Facility policy also required medications to be administered as ordered by the prescriber.
Failure to Notify Physician of Missed Orders and Treatment Changes
Penalty
Summary
The facility failed to notify the physician when there was a need to alter treatment for two residents. For one resident, who had diagnoses including pyelonephritis, head injuries, and quadriplegia, a physician ordered a UTI Panel to be obtained before starting antibiotics. The medical record showed that the urine specimen was not collected as ordered, and there was no documentation that the physician was notified of this omission before antibiotics were started. Interviews with nursing staff and administration confirmed that the specimen was not obtained and the physician was not informed prior to initiating treatment. For another resident with a history of traumatic brain injury, bipolar disorder, anxiety, major depressive disorder, and behavioral syndromes, there was a new order for Depakote to be administered twice daily. The resident missed two doses of Depakote due to issues with medication reconciliation and documentation on the MAR. Nursing staff did not notify the physician about the missed doses. The DON confirmed that staff are expected to notify the physician if they are unable to carry out an order, and acknowledged that there was no documentation of physician notification regarding the missed medication.
Failure to Provide and Document Scheduled Tracheostomy Cannula Change
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive a scheduled tracheostomy outer cannula change as ordered by the physician. The resident, who had diagnoses including head injuries, quadriplegia, and tracheostomy status, had a physician order for the cannula to be changed monthly on a specific day. Review of the medication administration record (MAR) for the relevant month showed that the cannula change was not documented as completed on the scheduled day or at any other time during the month. Interviews with facility staff, including the ADON, DON, and the LVN assigned to the resident on the scheduled day, confirmed that there was no documentation of the procedure being performed. The LVN stated she may have forgotten to document, but acknowledged that if it was not documented, it was not done. The facility's tracheostomy care policy required that tracheostomy tubes be changed as ordered, at least monthly. The DON confirmed that the expected practice was for staff to provide the required tracheostomy care and that all nurses were trained on this procedure.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for bed mobility and incontinent care was left unsupervised by only one CNA during care. The resident, an elderly female with multiple diagnoses including morbid obesity, muscle weakness, dementia, and a history of cerebral infarction, was documented in her care plan, Kardex, and MDS assessments as needing two staff members for bed mobility and transfers. Despite these documented requirements, the CNA proceeded to provide care alone, resulting in the resident sliding off the bed and sustaining a significant injury. The incident took place when the CNA attempted to change the resident's brief without waiting for a second staff member, as required by the resident's care plan and facility protocols. The resident slid off the bed, landing on her feet, but her knees buckled due to her inability to bear weight, and she was guided to the floor. Following the fall, the resident complained of pain in her right knee, and subsequent assessment and x-ray revealed an acute fracture of the right distal femur, necessitating hospitalization and surgical intervention. Interviews and record reviews confirmed that the CNA was aware of the two-person assist requirement but cited staffing shortages as the reason for acting alone. Other staff members and nursing leadership confirmed that the resident's care plan and Kardex clearly indicated the need for two-person assistance for bed mobility and transfers. The failure to follow established protocols and provide adequate supervision directly led to the resident's fall and injury.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by federal regulations. Specifically, a resident with a history of schizophrenia, anxiety, schizoaffective disorder, and substance abuse reported to the admission coordinator that an unidentified CNA was verbally and physically aggressive and that he feared for his safety. The admission coordinator did not immediately report this allegation to the abuse coordinator or the administrator. Record review showed that the resident was cognitively intact and able to make himself understood. The resident alleged that a CNA entered his room, was yelling, being aggressive, would not let him call the police, and yanked the phone out of his hand. The incident was documented in a grievance/complaint report by the admission coordinator, but the administrator and DON were not designated to investigate until the following day. The facility did not report the allegation to the state agency until more than two hours after the admission coordinator was informed, which was outside the required reporting timeframe. Interviews with facility staff confirmed that the admission coordinator received the allegation but did not recall the exact time and did not immediately report it, despite being trained on abuse and reporting requirements. The administrator acknowledged that the delay in reporting placed residents at risk. The facility's own policies required immediate reporting of suspected abuse to the administrator and authorities, but these procedures were not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the implementation of enhanced barrier precautions (EBP) during wound care for two residents. In one instance, a nurse (LVN B) provided wound care to a resident with a deep tissue injury on the right lateral ankle without wearing a gown, as required by EBP protocols. Although hand hygiene was performed and gloves were used, the omission of a gown during the procedure was acknowledged by the nurse, who stated that not wearing a gown could harbor bacteria. In another case, a different nurse (LVN C) performed wound care for a resident with pressure ulcers and moisture-associated skin damage on both heels. While a gown was worn, the nurse failed to follow proper infection control practices, including not performing hand hygiene at critical points, retrieving supplies from her scrub pockets under the gown with potentially contaminated hands, and not cleaning the wound cleanser bottle before returning it to the treatment cart. The nurse also removed her gown outside the room and did not perform hand hygiene before or after leaving the resident's room. Interviews with staff, including the Infection Preventionist, confirmed that the observed practices did not align with facility policy or CDC guidelines for EBP. The facility's infection control policy and CDC resources both require the use of gown and gloves for high-contact care activities and emphasize the importance of hand hygiene and proper handling of supplies. Requested documentation of infection control in-services and policies specific to EBP was not provided prior to the survey exit.
Failure to Protect Residents from Abuse by Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, specifically failing to prevent a resident from physically abusing other residents. The incidents involved a resident with a history of schizophrenia, OCD, and aggressive behavior, who repeatedly assaulted other residents over several months. Despite being aware of the resident's aggressive tendencies, the facility did not implement adequate supervision or specific interventions to prevent further incidents. The resident in question had a documented history of aggressive behavior, including hitting and pushing other residents, resulting in injuries such as a head laceration that required medical attention. The facility's care plans and interventions were insufficient, lacking specific measures to prevent the resident's aggression towards others. Staff interviews revealed a lack of awareness and understanding of the resident's monitoring requirements, contributing to the failure to protect other residents from harm. The facility's response to the incidents was inadequate, as they did not consistently implement or update interventions to address the resident's behavior. Despite multiple incidents and attempts to find alternative placement for the resident, the facility continued to leave the resident unsupervised, leading to repeated instances of abuse. The facility's policies and procedures for monitoring and managing aggressive behavior were not effectively communicated or enforced among staff, resulting in ongoing risks to resident safety.
Failure to Investigate and Report Resident Abuse Incident
Penalty
Summary
The facility failed to investigate and report the findings of an incident involving two residents to the State Survey Agency within the required 5 working days. On 05/20/24, Resident #6, who has a history of cerebral infarction, hemiplegia, hemiparesis, aphasia, anxiety, and schizoaffective disorder, slapped Resident #7 in the dining room. Resident #6 was described as having severe cognitive impairment and was rarely understood by others. Following the incident, Resident #6 was placed on 1-1 monitoring and later transferred to a behavioral hospital. Resident #7, who has a history of cerebral infarction and depression, was able to make herself understood and was cognitively intact. She reported being hit on the arm by Resident #6, which resulted in active bleeding. The incident was witnessed by a staff member who intervened and separated the residents. Despite the incident being reported to the facility's administration and medical personnel, there was no completed investigation report available for review. The facility's policy requires that all reports of resident abuse be thoroughly investigated and reported to the appropriate agencies within five business days. However, the facility failed to comply with this policy, as there was no investigation report submitted to the State Survey Agency. This failure to investigate and report the incident could place residents at risk of further abuse.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to consult with the resident's physician when there was a need to alter treatment for two residents. Resident #68, a [AGE] year-old female with a history of stroke, schizoaffective disorder, and seizures, had multiple instances of elevated blood pressure that were outside the prescribed parameters. Despite these elevated readings, the physician was not notified, and the resident was administered clonidine without physician consultation. The nurse responsible admitted to not placing the elevated blood pressure readings on the 24-hour report, which was against the facility's expectations for handling such changes in condition. Similarly, Resident #71, a [AGE] year-old female with essential hypertension, had her metoprolol medication held multiple times due to her pulse being below the prescribed parameters. Despite this, there was no documentation indicating that the physician was consulted about the medication being held. The nurse responsible acknowledged the failure to notify the physician, and the Assistant Director of Nursing (ADON) confirmed that the expectation was to consult the physician when medications were held for two consecutive occasions. The facility's policy on medication therapy indicated that physicians should be consulted when medications are given in excessive doses, for excessive periods, or when clinically significant adverse consequences are observed. The failure to notify the physician in both cases could place residents at risk of not receiving appropriate medical treatments, potentially leading to severe illness or hospitalization.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure the rights of residents to be free from abuse or neglect for two residents. Resident #16, a female with schizoaffective disorder, was verbally abused by CNA D. The incident occurred when Resident #16 attempted to use the facility phone, and CNA D unplugged the phone, cursed at her, and called her derogatory names. This incident was witnessed by another CNA, who reported it to the LVN on duty. Despite the immediate report, the LVN failed to notify the Abuse Coordinator until the end of the shift. The facility eventually suspended and terminated CNA D following an investigation that confirmed the abuse allegations. Resident #28, an 85-year-old male with Alzheimer's and dementia, experienced physical abuse from his roommate, Resident #72. The incident occurred when Resident #72, who also had severe cognitive impairments, grabbed Resident #28's arm, causing redness. Staff intervened and separated the residents. Resident #72 was subsequently monitored and moved to another room before being sent to a behavioral hospital. The incident was reported to the ADON, who then reported it to the Abuse Coordinator. The facility's policy required immediate reporting of abuse allegations, which was not adhered to in this case. Both incidents highlight the facility's failure to protect residents from abuse and neglect. The verbal abuse of Resident #16 and the physical abuse of Resident #28 were not promptly reported to the appropriate authorities, as required by the facility's policies. These deficiencies indicate lapses in staff training, supervision, and adherence to abuse prevention protocols, putting residents at risk of further harm.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for three residents. Resident #16 experienced verbal abuse from CNA D, who cursed at her, called her derogatory names, and disconnected the facility phone to prevent her from making a call. This incident was reported late to the Abuse Coordinator, and CNA D was allowed to continue working during the shift. The DON and Administrator were not notified immediately as required by the facility's policy. Resident #28 was subjected to physical aggression from his roommate, who grabbed his right forearm, causing redness. The incident was observed by LVN M, who separated the residents and assessed Resident #28. The care plan for Resident #28 included interventions such as monitoring for pain and notifying the responsible party and hospice. However, the incident was not reported as an allegation of abuse within the required two-hour timeframe. Resident #72, who had a history of physical aggression and severe cognitive impairment, was involved in the incident with Resident #28. He was later transferred to a behavioral hospital. The Administrator and DON discussed the incident and decided it was not an allegation of abuse, leading to a delay in reporting. The facility's policy required any allegations of abuse to be reported within two hours, but this was not adhered to in this case.
Failure to Report Abuse Incidents Timely
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator and to HHSC within the 2-hour period for three residents. The first incident involved a verbal altercation between a CNA and a resident, where the CNA cursed at the resident and disconnected the facility phone to prevent the resident from making a call. This incident was not reported to the administrator or the State Agency within the required 2-hour timeframe. The CNA involved was suspended and later terminated, but the delay in reporting was a clear violation of the facility's policies and state regulations. The second incident involved a physical altercation between two residents. One resident grabbed the other's forearm, causing redness and indentations. This incident was also not reported to the administrator or the State Agency within the required 2-hour period. The staff involved in separating the residents and assessing the situation did not follow the proper reporting protocols, leading to a delay in addressing the issue. The third incident involved another physical altercation between two residents, where one resident grabbed the other's arm. The staff did not report this incident to the administrator or the State Agency within the required 2-hour period. The facility's failure to report these incidents in a timely manner could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. The facility's policies and protocols for preventing and identifying abuse were not followed, leading to these deficiencies.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in documenting special treatments and procedures. Resident #21, a female with quadriplegia and tracheotomy status, did not have her tracheostomy care accurately reflected in her MDS assessment. Despite receiving tracheostomy care twice daily, this was not captured in her MDS, which was confirmed by the MDS nurse and the Director of Nursing (DON). The MDS nurse admitted to missing this information and stated there was no backup to double-check her work. Similarly, Resident #40, a male with chronic kidney disease and dependence on renal dialysis, did not have his dialysis treatments documented in his MDS assessment. Although he received dialysis three times a week, this was not recorded in his MDS. The Regional Reimbursement Coordinator and the DON both acknowledged that the dialysis treatments should have been documented. The DON and the Administrator confirmed that the MDS nurse was responsible for the accuracy of all MDS assessments and that the Regional Reimbursement Coordinator was supposed to act as a backup. The failure to document these special treatments and procedures accurately in the MDS assessments was attributed to oversight and lack of a double-check system. The Administrator and the Regional Nurse Consultant emphasized the importance of following the Resident Assessment Instrument (RAI) guidelines to ensure accurate documentation. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for improved accuracy in resident assessments to ensure proper care and facility compliance.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the facility did not trim the fingernails of a resident with severe cognitive impairment and contractures in the left hand. The resident, who had a history of hemiplegia/hemiparesis and a stroke, required partial/moderate assistance with personal hygiene. Despite care plans indicating the need for staff to check and trim the resident's nails on bath days and as necessary, observations over several days showed that the resident's fingernails were approximately 1/4 inch past the tips of the fingers and thumbs on both hands. The resident expressed a desire to have his nails cut, and staff members acknowledged that the nails were too long and needed trimming. Interviews with staff, including CNAs and the Director of Nursing (DON), confirmed that the resident's nails were not being maintained as required. The DON stated that the expectation was for staff to keep the resident's nails trimmed to prevent potential negative outcomes such as scratching or skin tears. The facility's policy on Activities of Daily Living (ADLs) indicated that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene, which was not adhered to in this case.
Failure to Provide Appropriate Range of Motion Treatment
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident #20, who had diagnoses of hemiplegia/hemiparesis and stroke, was ordered to receive a resting hand splint for the left hand and wrist to treat and correct contracture. However, the resident did not have the splint applied as ordered, and the care plan did not include interventions for the splint. Additionally, the resident's Treatment Administration Records (TARs) for April and May 2024 were blank and did not indicate that the splint was provided as treatment. Observations confirmed that the resident did not have the splint in place during multiple instances over several days, and interviews with staff revealed a lack of awareness and adherence to the physician's orders regarding the splint application. During observations and interviews, it was noted that Resident #20's left hand was severely contracted, and the resident expressed a desire to have his fingernails cut, as they could potentially cut into his skin. The resident mentioned that the splint was applied only sometimes, and staff interviews revealed inconsistencies in the application of the splint. The Restorative Aide (RA) and Occupational Therapy Assistant (OTA) both indicated that the resident had not been seen for range of motion exercises as frequently as required, and the splint was kept in the therapy office rather than being readily available for use. The Director of Therapy and the Director of Nursing (DON) acknowledged that the splint should have been in place as ordered and that the failure to apply the splint could lead to further contractures and a decrease in range of motion. The facility's policy on range of motion indicated that residents with limited range of motion should receive appropriate treatment and services to increase or prevent further decrease in range of motion, which was not followed in this case. This deficiency placed the resident at risk of not receiving the necessary care to maintain their highest level of well-being.
Failure to Administer Correct Oxygen Dosage
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not administer oxygen at the prescribed 2 liters per minute via nasal cannula for a resident with diagnoses including atrial fibrillation, morbid obesity, and tobacco use. Instead, the resident was observed receiving oxygen at 3 liters per minute on multiple occasions, contrary to the physician's order. The resident, who was bedfast and required a Hoyer lift for transfers, was unable to adjust the oxygen dosage independently. The discrepancy was noted during several observations and confirmed by both the LVN and ADON, who acknowledged the error and its potential negative outcomes, such as lung damage and carbon dioxide buildup. The resident's medical records, including the most recent quarterly MDS assessment and care plans, indicated the need for oxygen administration due to conditions like CHF and sleep apnea. Despite these documented needs and the physician's order, the facility staff failed to adhere to the prescribed oxygen dosage. The DON also confirmed that the nurses were expected to follow the orders and ensure the correct oxygen dosage was administered. The facility's Oxygen Administration policy, revised in October 2010, was not followed, leading to the resident receiving an incorrect oxygen dose, which could have serious health implications.
Failure to Document Vital Signs Before Administering Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not documenting blood pressure (BP) or heart rate (HR) before administering medications with specific parameters. This deficiency was identified for a resident with a diagnosis of hypertension who was prescribed metoprolol tartrate with instructions to hold the medication if BP or HR fell below certain levels. Despite the resident's condition and the prescribed parameters, the facility did not document the necessary vital signs on multiple occasions before administering the medication, as evidenced by the Medication Administration Record (MAR) and nurses' notes review. Interviews with the staff, including the Licensed Vocational Nurse (LVN), Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Staffing Coordinator, revealed that the BP and HR were not documented due to an oversight in the system and failure to trigger the necessary documentation. The LVN admitted to checking the resident's BP and HR but failing to document it, while the DON and ADON acknowledged the responsibility of ensuring proper documentation and auditing the charts. The Staffing Coordinator also admitted to not rechecking the orders for accuracy after adjusting the medication administration times. The deficiency was further confirmed by the facility's policy on medication administration, which mandates the documentation of vital signs when necessary. The failure to document BP and HR before administering metoprolol tartrate, as prescribed, was a significant oversight that could potentially lead to adverse effects for the resident. The staff interviews and record reviews highlighted a lapse in following the established procedures for medication administration and documentation, leading to the identified deficiency.
Failure to Hold Medication as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #71's drug regimen was free from unnecessary drugs. Specifically, the facility did not hold the administration of metoprolol tartrate when the resident's heart rate was outside the parameters set by the physician. Resident #71, a [AGE] year-old female with diagnoses including essential hypertension and heart failure, was prescribed metoprolol tartrate with instructions to hold the medication if the systolic blood pressure (SBP) was below 100, diastolic blood pressure (DBP) was below 60, or pulse was below 60. Despite these instructions, the medication was administered on three occasions when the resident's pulse was below the prescribed threshold: on 05/3/24 with a pulse of 47, on 05/9/24 with a pulse of 57, and on 05/10/24 with a pulse of 52. This was confirmed during an interview and record review with ADON A, who acknowledged that the nurses documented heart rates outside the prescribed parameters and still administered the medication, contrary to the physician's orders. The facility's policy on medication therapy emphasized the importance of tapering, discontinuing, or changing medications when given in excessive doses or without adequate monitoring, which was not adhered to in this case.
Failure to Employ Full-Time Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for approximately six months, from November 2023 to May 2024. During this period, the facility only had a social worker who worked on an as-needed basis and some weekends. Interviews with HR staff and the part-time social worker confirmed that the facility had been searching for a full-time social worker but had not yet hired one. The Administrator acknowledged the need for a full-time social worker due to the facility's licensed capacity of 199 beds, but efforts to fill the position had been unsuccessful. This deficiency was identified through interviews and record reviews conducted by surveyors.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that mandatory Quality Assurance and Performance Improvement (QAPI) training was provided to eight staff members, including the Dietary Supervisor, ADON W, LVN T, LVN U, Laundry Supervisor, CNA E, CNA X, and CNA V. Record reviews indicated that these staff members, hired between 1989 and 2022, had no documented QAPI training up to the date of the survey. This lack of training was confirmed through interviews with the HR representative and the Administrator, who acknowledged the oversight and stated that QAPI training was expected to be part of the computerized training system and in-service orientation for new hires. The HR representative admitted to not being informed of the new QAPI training requirement, while the Administrator expressed that she had conducted in-service training on QAPI during orientation for new hires since her tenure. Despite these expectations, the training records did not reflect compliance with the QAPI training requirement, potentially placing residents at risk due to staff not being adequately informed about the QAPI program and its goals.
Failure to Document Wound Care and Skin Assessments
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for four residents. Specifically, the facility did not document weekly wound assessments and ordered wound care for Resident #1, Resident #4, Resident #5, and Resident #6. This included missing documentation for wound care on specific dates and the absence of weekly skin assessments for multiple weeks. The lack of documentation could lead to incomplete or inaccurate records and inadequate care for the residents involved. Resident #1 had a trauma wound on the left inner ankle, and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The resident's care plan did not address the assessment, care, and treatment of the wound. During an interview, the resident mentioned that wound care was provided daily but had been missed a few times. The treatment nurse confirmed that wound care was provided but admitted to possibly forgetting to document it in the electronic medical records. Resident #4 had multiple pressure injuries and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The treatment nurse and other staff members confirmed that wound care was provided but admitted to possibly forgetting to document it. Resident #5 had a stage 3 pressure ulcer on the left buttock, and the facility failed to document weekly wound assessments and ordered wound care on several specified dates. The resident mentioned that wound care was provided daily, but the treatment nurse admitted to possibly forgetting to document it. Resident #6 had potential skin integrity issues, and the facility failed to document weekly skin assessments for multiple weeks. The treatment nurse confirmed that skin assessments were performed but admitted to possibly forgetting to document them in the electronic medical records.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to Resident #2 after his return from an inpatient stay at a behavioral health hospital. Resident #2 had been admitted to the behavioral health hospital following a resident-to-resident altercation involving aggressive behavior. Despite the discharge paperwork indicating the need for follow-up psychiatry services, the facility did not conduct a psychiatric assessment or initiate behavior or mood monitoring for Resident #2 upon his return. This oversight persisted from his return on 02/23/2024 until the survey date on 04/16/2024. Resident #2, who has diagnoses including Major Depressive Disorder, Impulse Disorder, and Anxiety Disorder, was involved in an altercation with Resident #3 over a pair of pajama pants. During the incident, Resident #2 exhibited aggressive behavior by rolling towards Resident #3 with a fork in his hand and later being found with a pair of scissors. Despite these behaviors, the facility did not update Resident #2's care plan to reflect his potential risk for aggression or behaviors, nor did they ensure he received the necessary behavioral health services upon his return. Interviews with facility staff, including the MDS Coordinator, LVN, and DON, revealed that they were aware of the altercation and the need for a psychiatric assessment for Resident #2. However, no such assessment was conducted, and no behavioral monitoring was initiated. The facility's policy on Behavioral Assessment, Intervention, and Monitoring, which mandates providing behavioral health services to maintain residents' highest practicable physical, mental, and psychosocial well-being, was not followed in this case.
Inadequate Supervision Leading to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was totally dependent on two staff members for bed mobility, transfers, and toilet use. On the date of the incident, a CNA provided incontinent care to the resident without assistance from another staff member, which resulted in the resident rolling off the bed and sustaining a small left anterior frontal scalp hematoma. The resident was transferred to the hospital for evaluation and treatment, where a CT scan showed no irregularities, and the resident was later returned to the facility. The resident's care plan and Kardex clearly indicated that she required the assistance of two staff members for bed mobility and other activities of daily living. Despite this, the CNA proceeded to provide care alone, stating that she did not see any available CNA to ask for assistance and did not check the Kardex to verify the required level of care. The CNA mentioned that during her orientation, she was told by another CNA that if she felt comfortable, she could perform the resident's care by herself. Interviews with the facility's administrator and other staff members revealed that the CNA did not follow the care guide on the resident's Kardex, and there was no reason for her to provide care without a second staff member as the facility was not short-staffed. The administrator confirmed that all staff were trained during orientation to follow the Kardex care guide, but the incident highlighted a lapse in adherence to this protocol. The facility's investigation report and staff interviews corroborated that the CNA did not request assistance from other available staff members, leading to the resident's fall and injury.
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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