Castle Hills Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 8020 Blanco Rd, San Antonio, Texas 78216
- CMS Provider Number
- 455510
- Inspections on file
- 48
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 44 (1 serious)
Citation history
Health deficiencies cited at Castle Hills Rehabilitation And Care Center during CMS and state inspections, most recent first.
Surveyors found two nurse medication carts, one on the south hall and one on the north hall, left unlocked and unattended during a med pass. On the south hall, an RN who worked only as needed left the cart in front of the nurse’s station with drawers facing the hallway and no staff present, later stating she forgot to lock it and acknowledging it was her responsibility to do so. On the north hall, an LPN who regularly worked that shift left her cart unlocked in front of a resident’s room while she went to the nurse’s station around the corner, stating she could see the cart, no residents were nearby, and she was gone only briefly. The DON stated that nurses assigned to carts are responsible for locking them when unattended and that leaving carts unlocked places residents at risk of taking medications not prescribed for them, contrary to the facility’s Medication Storage policy requiring meds to be under direct observation or locked.
A resident admitted with a diagnosis of sacral pressure ulcer and documented stage 2 pressure ulcers on both buttocks was inaccurately coded on the admission MDS as having no unhealed pressure ulcers/injuries. Wound assessments and physician orders confirmed bilateral buttock stage 2 pressure ulcers requiring daily treatment, and the care plan addressed heel deep tissue injuries but not the buttock ulcers. The wound care LVN and a hospital nurse verified the presence of the buttock pressure ulcers, and the DON later acknowledged that Section M of the MDS should have been coded to reflect one or more unhealed pressure ulcers, contrary to facility policy requiring complete and accurate documentation.
A resident admitted with a sacral pressure ulcer had documented stage 2 pressure ulcers on both buttocks and physician orders for daily wound care, but the comprehensive care plan only addressed heel deep tissue injuries and omitted the buttock pressure ulcers entirely. The admission MDS inaccurately indicated no unhealed pressure ulcers, and the DON later acknowledged that no specific care plan was developed for the buttock wounds despite wound care being provided and facility policy requiring comprehensive, measurable care plans for all identified conditions.
A resident with stage 2 pressure ulcers on both buttocks had a physician order for daily application of triad with collagen particles, but the Treatment Administration Record lacked nursing initials on three treatment days. The care plan addressed heel injuries but did not include the buttock pressure ulcers. An LVN and another LVN each stated they provided the ordered wound care on their respective shifts but forgot to document it, while an RN stated she applied the triad with collagen particles but did not document because she did not view cream application as wound care. The DON confirmed that this treatment was wound care and should have been documented per facility policy.
A resident with bacteremia, MRSA, peripheral vascular disease, and septicemia had an order for cefazolin 2 g IV every 8 hours, with the pharmacy label directing infusion of 2 g/50 mL over 30 minutes at 100 mL/hr. During observation, an RN set the IV pump to 75 rather than the labeled 100, based on a misreading of the prescription, while the DON later stated that pharmacy establishes the rate and that it is printed on the IV bag. The MAR reflected the IV antibiotic order and administration, and interviews with the DON and MD confirmed that the medication was given at a slower rate than specified on the pharmacy label.
A resident with cerebral palsy, profound intellectual disabilities, neuromuscular bladder dysfunction, severe cognitive impairment, and an indwelling Foley catheter was observed in bed with the Foley drainage bag hung vertically so that the bottom of the bag was touching the floor. Staff, including a CNA, an RN, and the DON, acknowledged that Foley bags should be kept below the bladder, secured to a non-movable part of the bed, placed in a privacy cover or basin, and not allowed to touch the floor due to contamination and infection control concerns. Despite an existing catheter care policy and staff training, the Foley bag for this resident was not maintained in accordance with infection prevention and control practices.
Surveyors observed that the kitchen was dirty, with dirt, grease build-up, and debris present in multiple areas, and staff including the FSS, dieticians, and DON were unable to explain the lack of cleanliness and sanitation despite facility policy requiring regular inspections.
Multiple overhead ceiling lights in the kitchen, including those over the 3-sink area, cooking table, and pantry, were found to be non-functioning during a food service sanitation inspection. Staff interviews revealed no explanation for the lack of lighting or missing work orders, and the facility's policy requires regular inspections to ensure compliance with sanitation and safety standards.
Two licensed nurses were found to have expired CPR certifications, and the facility did not have a formal competencies policy or checklist to ensure ongoing compliance. The HR and DON were aware of the expired certifications but did not ensure timely renewal, relying instead on reminders and the presence of other CPR-certified staff during shifts. This failure did not align with the facility's policy requiring current CPR certification for all licensed staff.
Surveyors identified multiple deficiencies in kitchen sanitation and food storage, including the presence of dirt, debris, and flying insects in food preparation areas, as well as unlabeled and undated food items in both refrigeration and dry storage. Facility staff were aware of some maintenance issues but not the full extent of cleanliness and labeling lapses.
A facility failed to maintain an effective pest control program, resulting in flying insects being observed in a resident's room and the communal dining area. A resident with end-stage renal disease reported frequent flies in his room and in dining areas, describing the situation as disruptive and unsanitary. During meal service, multiple residents were seen swatting at insects landing on their bodies and food. The administrator was aware of intermittent insect issues, and a pest control invoice documented a significant presence of fungus gnats and recommended environmental repairs.
A resident with severe cognitive impairment and a history of dementia eloped from the facility at night, crossing a busy road before being found at a bus stop by an off-duty CNA. The incident occurred due to multiple failures, including non-functioning door alarms, lack of alarm activation by the receptionist and nurse, and inadequate monitoring during a shift change, despite the resident being identified as a moderate elopement risk.
A resident with cerebral palsy and complex medical needs was identified by the LIDDA as requiring a customized DME wheelchair, but the facility failed to submit the required PASARR specialized services request to the State Agency within the mandated 20 business days. The responsible social worker did not complete the submission due to lack of awareness of the deadline and delays in securing the equipment, and the facility's policy did not address this requirement.
A suspected abuse incident involving a CNA and a male resident with multiple chronic conditions was not reported to the State Survey Agency within the required two-hour timeframe. Although the incident was promptly reported internally and the CNA was suspended, the administrator delayed external reporting until the following afternoon, contrary to facility policy and regulatory requirements.
A newly admitted resident with a Foley catheter and active UTI did not have a baseline care plan developed and implemented within 48 hours that included necessary instructions for catheter care and antibiotic use. Despite clear documentation from the hospital and nursing notes about the resident's catheter and infection, the care plan lacked specificity and failed to address these needs, leading to hospitalization for sepsis. Staff interviews confirmed the care plan was not individualized or comprehensive.
A resident with significant neurological impairment and an indwelling Foley catheter was admitted without proper physician orders or documentation for catheter care, monitoring for infection, or tracking of urinary input/output. Despite care plan references, there was no evidence of routine catheter care or monitoring, and staff interviews revealed confusion about the resident's catheter status. The resident experienced multiple falls, ongoing UTI treatment, and was ultimately hospitalized with sepsis and a distended bladder, with hospital records indicating catheter dysfunction.
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for two residents. A resident with sepsis/osteomyelitis and another with multiple sclerosis and chronic kidney disease did not receive their prescribed antibiotics correctly. Medications were found unlabeled in a cart, and a medication aide was improperly instructed to administer them. The facility's policy requiring the person who dispenses the medication to administer it was not followed, leading to a deficiency in pharmaceutical services.
A facility failed to maintain proper infection control practices during incontinent care for a resident requiring enhanced barrier precautions. CNA A did not change gloves or perform hand hygiene after cleaning stool, and both CNA A and CNA B did not wear gowns as required. The resident had multiple health issues, including chronic wounds, necessitating strict adherence to infection control protocols. Despite training, the facility's staff did not follow established procedures, leading to potential infection risks.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their records. A resident's smoking habit was not reflected in their MDS, while two other residents had incorrect medication information recorded, with anticoagulants mistakenly noted. These errors were acknowledged by the MDS nurse, highlighting potential risks for inadequate care.
The facility failed to properly label and date open food items and maintain appropriate storage temperatures in their kitchen. Observations revealed unlabeled food in the reach-in freezer and refrigerator, moldy strawberries in the walk-in cooler, and a reach-in refrigerator temperature of 60 degrees. The Dietary Manager and Dietitian acknowledged these issues, which contravened the facility's policies and the U.S. FDA Food Code.
A resident with multiple diagnoses, including ESRD and MDD, was found with the call light out of reach, contrary to their care plan. The DON confirmed the oversight, highlighting the importance of following person-centered care plans. The facility's policy mandates call light accessibility, which was not adhered to in this instance.
A resident with a history of falls and multiple diagnoses, including ESRD and A-fib, was observed in a low bed without a fall mat, contrary to their care plan. The DON confirmed the absence of the fall mat, highlighting the importance of following care plans to ensure resident safety. The facility's policy stresses the need for a hazard-free environment and consistent implementation of interventions.
A resident with severe cognitive impairment and incontinence issues did not receive proper incontinent care when a CNA failed to return the foreskin to its original position after cleaning. This oversight, observed during a survey, could lead to infection and other complications. The resident's care plan required regular checks and assistance, and the CNA had been trained in proper procedures.
A deficiency was identified in a LTC facility when a CNA failed to reposition a resident's foreskin after providing incontinent care, despite having completed competency training. The resident, who had severe cognitive impairment and other medical conditions, was at risk due to this oversight. The facility's policy required the foreskin to be repositioned, which was not followed by the CNA.
A facility failed to ensure proper pharmaceutical services by allowing expired thickened lemon flavor water to remain on a medication cart. The medication aide was unaware of the expiration, and the DON confirmed the oversight, acknowledging that expired products should be discarded according to facility policy.
A facility failed to secure medications properly, leaving a resident's sterile water unattended in their room. The resident, with severe cognitive impairment, required catheter flushing due to urinary tract infections. Staff interviews confirmed that medications should not be left unattended, highlighting a breach in the facility's medication storage policy.
A resident with severe cognitive impairment and multiple health issues was not provided with a built-up spoon during meal service, as required by their care plan and meal ticket. Despite the facility's policy to provide adaptive devices, the resident was given a regular spoon due to the kitchen staff's inability to locate the correct utensil.
A resident's bed headboard was found to be loose and swinging, posing a potential risk for injury. Despite the resident's discomfort, the issue was not reported to staff. Interviews with an LVN and Medical Record and Equipment staff confirmed the oversight, acknowledging the responsibility to ensure equipment safety. The facility's policy prioritizes accident prevention and resident safety.
A resident with moderate cognitive impairment and a history of elopement managed to leave the facility unsupervised, despite being identified as an elopement risk. The resident was last seen in the smoking courtyard and was later found by police approximately 688 feet away from the facility. The facility's elopement protocol was initiated after the resident was discovered missing, but the incident indicates a failure in supervision and monitoring.
The facility failed to prevent two residents from eloping, one of whom was found by police and the other whose whereabouts remain unknown. The incidents revealed significant lapses in monitoring, security measures, and staff training.
The facility failed to prevent two residents from eloping, leading to one resident being found by police and another still missing. The facility lacked adequate supervision, monitoring, and security measures, placing residents at significant risk.
The facility failed to notify physicians when residents were administered blood pressure medications outside of ordered parameters, leading to potential delays in needed treatment. Four residents received medications despite low blood pressure readings without physician notification.
The facility failed to ensure proper administration of medications for four residents, leading to significant medication errors. Medications to lower blood pressure were given despite low blood pressure readings, and there was no documentation of physician notification. The DON and LVNs stated they manually took vital signs, but the system's copy feature was later removed.
The facility failed to maintain complete and accurately documented medical records for seven residents, with blood pressures and vital signs documented as the same on different shifts and days. Interviews revealed a systemic issue with the use of a feature that allowed the use of the last documented vital signs, which has since been removed.
The facility failed to develop a comprehensive care plan for a resident with multiple complex diagnoses, omitting vital information necessary for proper care. The care plan lacked details on several of the resident's conditions, which could lead to insufficient care.
Unlocked and Unattended Medication Carts on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments on two medication carts observed during survey. On the south hall, surveyors observed a nurse cart at 8:28 AM positioned in front of the nurse’s station with the drawers facing the hallway, unlocked and unattended, with no staff present at the nurse’s station. RN A, who reported she was not regular staff and only worked when needed, stated in interview that she had been passing medications to a resident and forgot to lock the cart when she walked away. RN A acknowledged that carts needed to be locked when staff walked away to prevent residents from taking medications that did not belong to them and stated it was the nurse’s responsibility to ensure carts were locked when they leave them. On the north hall, surveyors observed another nurse cart at 8:42 AM in front of a resident’s room with drawers facing the doorway, also unlocked and unattended, while the nurse was at the north hall nurse’s station around the corner from the cart. LPN B, who regularly worked the 6:00 AM to 2:30 PM shift on the north hall, stated she could see her cart, no residents were around when she walked away, and she had only gone to the nurse’s station for a few seconds. When asked how leaving the cart unlocked could have affected residents, she responded that it could not affect them since it was within her sight and then pushed the cart away from the surveyor and did not answer further questions. The DON stated that staff assigned to nurse or medication carts were responsible for ensuring they were locked before leaving them unattended, that both nurses were experienced and should not have left their carts unlocked, and that leaving a cart unlocked placed residents at risk of taking medications not prescribed for them, which could cause adverse effects including illness or hospitalization. Facility policy on Medication Storage required that during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
Inaccurate MDS Coding for Resident With Documented Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate admission MDS assessment for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of sacral pressure ulcer, had an admission MDS dated 02/03/2026 that coded Section M (Skin conditions) as indicating no unhealed pressure ulcers/injuries. However, the resident’s face sheet listed a diagnosis of pressure ulcer of the sacral region, and a wound care assessment dated 02/02/2026 documented stage 2 pressure ulcers on the left and right buttock. A physician order dated 02/04/2026 directed daily wound care to the left and right buttock stage 2 pressure ulcers using triad with collagen particles. Further record review showed the comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to both heels with interventions such as a pressure-reducing mattress, skin care, treatment, and turning/repositioning, but did not include a care plan for the resident’s buttock pressure ulcers. During interviews, a hospital nurse and the facility’s wound care LVN confirmed the presence of stage 2 pressure ulcers on both buttocks at admission and that wound care was being provided. The DON acknowledged that the admission MDS was inaccurate regarding pressure ulcers and stated that Section M should have been coded to reflect one or more unhealed pressure ulcers/injuries. The facility’s policy on documentation required each resident’s medical record to contain a complete and accurate representation of the resident’s status and progress.
Failure to Care Plan for Resident’s Buttock Pressure Ulcers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of a sacral pressure ulcer, had an admission MDS that incorrectly indicated she did not have any unhealed pressure ulcers or injuries. Her comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the right and left heels, with interventions such as a pressure-reducing mattress, skin care, treatment, and a turning and repositioning schedule, but it did not include any care plan problem, goals, or interventions for pressure ulcers to the right and left buttock areas. Further record review showed that a wound care assessment on 02/02/2026 documented stage 2 pressure ulcers on the resident’s left and right buttocks, and a physician’s order dated 02/04/2026 directed daily wound care to those areas using triad with collagen particles. Interviews with the hospital nurse confirmed the presence of stage 2 pressure ulcers to the buttocks, and the facility’s wound care LVN stated that the resident had unhealed stage 2 pressure ulcers to the left and right buttocks upon admission and that wound care was provided as ordered. The DON acknowledged that there was no specific care plan for the stage 2 buttock pressure ulcers and attributed this to an inaccurate MDS assessment, despite the facility’s policy requiring a comprehensive care plan with measurable objectives and timeframes for all needs identified in the comprehensive assessment.
Incomplete Documentation of Ordered Wound Care on Treatment Administration Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with professional standards for one resident receiving wound care. A 65-year-old female resident was admitted with pressure-related skin issues, including deep tissue injuries to both heels and, per a wound care assessment dated 02/02/2026, stage 2 pressure ulcers on the left and right buttocks. The comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to the heels but did not include a care plan for the resident’s stage 2 pressure ulcers on the buttocks. A physician’s order dated 02/04/2026 directed daily application of triad with collagen particles to the stage 2 pressure ulcers on the left and right buttocks. Review of the Treatment Administration Record (TAR) for 02/01/2026 through 02/28/2026 showed that the ordered wound care was not initialed as given on 02/01/2026, 02/07/2026, and 02/08/2026. LVN-B reported working on 02/01/2026 and providing the ordered wound care but stated she forgot to document it on the TAR. LVN-A reported working on 02/07/2026, providing the ordered triad with collagen particles once daily and leaving the area open to air, but also forgot to document on the TAR. RN-C reported working on 02/08/2026, providing the triad with collagen particles to the buttock pressure ulcers, but did not document because she did not consider applying cream with collagen particles to be wound care. The DON confirmed that applying triad with collagen particles to the stage 2 buttock ulcers was considered wound care and that nurses should have documented these treatments on the TAR, consistent with the facility’s documentation policy requiring licensed staff to document all services at the time of service or by the end of the shift.
Incorrect IV Antibiotic Infusion Rate Due to Nurse Misinterpretation of Pharmacy Label
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration of an IV antibiotic in accordance with pharmacy directions for one resident. The resident was an elderly male with diagnoses including bacteremia, MRSA infection, peripheral vascular disease, multidrug-resistant organism, and septicemia. His admission and annual MDS assessments showed a decline from cognitively intact (BIMS 15) at admission to severely cognitively impaired (BIMS 0) at the time of the annual assessment. He had active orders for cefazolin sodium 2 g IV every 8 hours for MSSA to both lower extremities, with the pharmacy label specifying CEFAZOLIN 2G/50 ML-DEXTROSE to be activated, mixed, and infused intravenously over 30 minutes at a rate of 100 mL/hr every 8 hours. The MAR reflected this IV antibiotic order and documented administration by RN A. During surveyor observation, the resident was noted to have a PICC line in the left upper arm and reported no issues with IV medication administration. Later observation showed RN A administering the cefazolin IV and setting the infusion pump rate at 75 (mg/hr), despite the IV bag label indicating administration at 100 (mL/hr). In interviews, the DON acknowledged that administering at 75 versus 100 would result in a slower rate and stated she expected nurses to check the rate, noting that the rate was printed on the IV bag and set by the pharmacy because hospital discharge orders did not include a rate. RN A stated the medication was to be titrated over one hour and reported misinterpreting the prescription, believing 100 referred to volume and 75 to the rate. MD B stated that administering the medication at 75 instead of 100 was medically acceptable and would only prolong the administration time. No facility policy on medication administration was requested for review.
Improper Foley Catheter Bag Positioning and Infection Control Lapse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program by not ensuring proper positioning of an indwelling Foley catheter drainage bag for one resident. The resident was an adult male with cerebral palsy, profound intellectual disabilities, neuromuscular dysfunction of the bladder, severe cognitive impairment (BIMS score of 0/00), range of motion impairment in all extremities, wheelchair use, and dependence for self-care and mobility. He had an indwelling catheter in place for a neurogenic bladder, with an active order for the catheter and a care plan addressing the indwelling catheter. During observations, the resident was seen in bed with his Foley catheter bag hung vertically with the bottom of the bag touching the floor. Staff interviews confirmed that the observed Foley bag position was inconsistent with facility expectations and training. A CNA who normally worked on the resident’s hall stated that Foley bags were supposed to be set up under the bed on the side, vertical, in a privacy bag, and not touching the floor, and acknowledged that a bag touching the floor would be considered contaminated. An RN stated that nurses were responsible for ensuring Foley bags did not touch the floor, that the bag should be lower than the resident, hung on a non-movable part of the bed, and not touching the floor due to contamination risk. The DON stated that nurses and CNAs were responsible for ensuring Foley bags were appropriately placed or in a basin so they did not touch the floor, and that it would be an infection control concern if the bag touched the floor, although she later stated she did not believe the bag touching the floor would have impacted this resident because the bag was enclosed. The facility’s catheter care policy stated it was the policy to ensure residents with indwelling catheters receive appropriate catheter care, but the observed practice did not align with this standard.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by observations of a dirty kitchen. During an inspection, surveyors observed dirt, grease build-up, and debris under the juice table, pantry floor, steam table, and cooking table. Multiple staff interviews, including with the Food Service Supervisor (FSS), two dieticians, and the Director of Nursing (DON), revealed that none could provide an explanation for the lack of cleanliness and sanitation in the kitchen. The FSS stated he had attempted to clean the kitchen the previous night without assistance, while both dieticians acknowledged the need for cleanliness and sanitation but could not explain the deficiency. Record review showed that the facility's policy required regular sanitation inspections to ensure food service areas were clean, sanitary, and compliant with regulations. Despite this policy, the kitchen was found to be in an unsanitary condition during the survey, and staff were unable to account for the failure to maintain proper standards of cleanliness and sanitation in the food service area.
Failure to Maintain Safe Operating Condition of Kitchen Equipment Due to Inadequate Lighting
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in the kitchen, as evidenced by multiple non-functioning overhead ceiling lights. During an observation, it was noted that three ceiling lights were not working over the 3-sink area, two lights were out over the cooking table, and two additional lights were not functioning in the pantry. This lack of adequate lighting was observed during a food service sanitation and safety inspection. Interviews with the Food Service Supervisor (FSS), two dieticians, and the Director of Nursing (DON) revealed that none could provide an explanation for the non-functioning lights or why work orders had not been submitted for their replacement. The FSS confirmed there was no work order in place, and the DON stated that the FSS had been educated on the need to submit work orders when necessary. Review of the facility's Sanitation Inspection policy indicated that regular inspections are required to ensure compliance with sanitation and safety regulations.
Failure to Ensure Current CPR Certification for Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that all licensed nursing staff possessed current Basic Life Support (CPR and AED) certifications, as required by facility policy and national standards. Specifically, two nurses, an RN and an LPN, were found to have expired CPR certifications at the time of review. The HR was responsible for checking certifications during onboarding and sent monthly reminders to staff with expired certifications, escalating to the DON after multiple reminders. Despite being aware of the expired certifications, both the HR and DON did not ensure that the certifications were renewed in a timely manner. The DON stated that competencies were reviewed upon hire and annually, but there was no formal competencies policy or checklist in place. Interviews with the DON, HR, and the affected RN revealed that the facility relied on documentation of certification to verify competency, and there was no evidence that either nurse worked shifts without another CPR-certified nurse present. The facility's policy required that CPR-certified staff be available at all times and maintain current certification through an approved provider. However, the lack of current certification for these two nurses represented a failure to comply with the facility's own policy and procedures regarding staff competencies and resident safety.
Deficient Food Storage, Labeling, and Sanitation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and cleanliness. The kitchen and refrigeration areas were found to have dirt and debris, including a layer of white and brown debris on the floor, trash behind the refrigerator, broken tiles exposing damaged drywall, and a wet, black substance around the dishwashing area plumbing and on ceiling tiles. Additional dirt and debris were noted along the edges of the floors and underneath storage racks in the walk-in refrigerator. The plumbing of the handwashing sink had an open, exposed pipe, and the wall trim beneath was peeling, exposing stained and damaged drywall. Multiple flying insects were present in the food preparation and distribution areas. Food storage practices were also deficient. In the walk-in refrigerator, trays of beverages portioned into single-serve cups were not labeled or dated, and in the dry storage area, several bags of bread buns and rolls were not labeled or dated. Interviews with the Dietary Services Manager (DSM) and the Administrator revealed awareness of some ongoing maintenance issues, such as plumbing and broken tiles, but a lack of awareness regarding the extent of dirt, debris, and current insect presence. The DSM acknowledged that labeling and dating of prepared foods and bread items were not consistently performed according to facility policy.
Failure to Maintain Effective Pest Control in Resident Room and Dining Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects in both a resident's room and the communal dining area. Observations confirmed that flying insects were present in a male resident's room, who had end-stage renal disease and intact cognition, and the resident reported that flies were consistently present in his room as well as in the kitchen and dining areas. The resident described the situation as disgusting. During meal service in the communal dining area, multiple flying insects were observed, causing residents to swat at them as they landed on their bodies and food. The same resident confirmed that flies were always present during meals, which he found disruptive and dirty. The facility administrator acknowledged awareness of intermittent insect issues in the facility, including in residents' rooms, but was unaware of the specific incident in the dining area. Review of the most recent pest control invoice documented the discovery of a significant number of fungus gnats and included recommendations for prevention, such as removing standing water, repairing damaged floors and walls, and fixing faulty plumbing. Despite a request, the facility's pest control policy was not provided prior to the survey exit.
Failure to Prevent Elopement Due to Lapses in Supervision and Door Alarm Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia, Alzheimer's disease, and hypertension eloped from the facility at night. The resident was ambulatory and had been assessed as a moderate risk for elopement, with a care plan in place that included frequent rounding and monitoring. On the evening of the incident, the resident was observed wandering throughout the facility and was last seen following staff members down the hall. The resident subsequently exited the building, crossed a busy five-lane road, and was found at a bus stop by an off-duty CNA. The investigation revealed multiple failures in the facility's supervision and safety protocols. The inside door to the front lobby had a charm and keypad, but the wandering alert system and electronic magnetic lock were not functioning. The front door was secured only by a deadbolt and lacked an alarm or delay system. The receptionist, whose desk was adjacent to the front door, left her post to purchase dinner and did not activate the foyer alarm as required by protocol. Additionally, the nurse responsible for setting the keypad at 8:00 PM did not do so, and this lapse was not verified by another staff member as required. Staff interviews confirmed that the alarm was not set, and the resident was able to leave the facility undetected during a shift change. Documentation and staff statements indicated that the facility had an elopement protocol and policies requiring monitoring of residents at risk for wandering, regular checks of door alarms, and verification of alarm activation. However, these protocols were not followed on the night of the incident. The receptionist did not arm the foyer door, the nurse did not verify or set the alarm, and there was no effective monitoring of the resident during the critical period. The facility's own root cause analysis identified the failure to set the foyer alarm and the absence of the receptionist at the front desk as the primary causes of the elopement.
Failure to Timely Submit PASARR Specialized Services Request for Resident Needing Custom Wheelchair
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program as required, specifically by not submitting a request for Nursing Facility Specialized Services (NFSS) for a resident within the mandated 20 business day timeframe. The resident, who had cerebral palsy and was assessed as medically complex with intact cognition, was identified by the Local Intellectual and Developmental Disability Authority (LIDDA) as needing a customized DME wheelchair. Despite this recommendation being made during an interdisciplinary team (IDT) meeting, the facility did not submit the required NFSS request to the State Agency in a timely manner. Record reviews and interviews revealed that the social worker, responsible for submitting NFSS recommendations into the Texas Medicaid & Healthcare Partnership (TMHP) SimpleCFS website, did not complete the submission within the required period because the Director of Rehabilitation (DOR) had not secured the custom wheelchair from the vendor. The social worker was unaware of the 20-day submission requirement. Additionally, the facility's policy did not address the need to submit NFSS requests within this timeframe, as confirmed by the administrator. As a result, the resident did not receive the benefits of the LIDDA's recommendations in a timely manner.
Failure to Timely Report Suspected Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported within the required timeframes. Specifically, an incident was observed in which a certified nursing assistant (CNA) was seen kissing a male resident with chronic systolic heart failure, epilepsy, and chronic obstructive pulmonary disease. The incident occurred late in the evening and was immediately reported by another CNA to the Director of Nursing (DON), who then notified the administrator. Despite this, the administrator did not report the suspected abuse to the State Survey Agency (HHSC) within the mandated two-hour window. Instead, the report was made the following afternoon, well beyond the required timeframe. Interviews and record reviews confirmed that the administrator, who is responsible for reporting suspected abuse or neglect, was informed of the incident on the same night it occurred. The administrator stated that after ensuring the resident felt safe, he waited until the next day to begin the investigation and subsequently reported the incident to HHSC in the afternoon. Facility policy and staff training both required immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Develop and Implement Baseline Care Plan for New Admission with Foley Catheter and UTI
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan within 48 hours of admission that included all necessary instructions for effective, person-centered care for a newly admitted resident. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, and Wernicke's encephalopathy, was admitted with a Foley catheter and an active urinary tract infection (UTI) requiring antibiotics. Despite hospital discharge records and multiple nursing notes indicating the presence of a Foley catheter and ongoing antibiotic treatment, the facility's care plan did not specifically address the resident's catheter care or current UTI and antibiotic use. The medical record review revealed inconsistencies and omissions regarding the resident's catheter status and care. The Minimum Data Set (MDS) did not reflect the presence of an indwelling catheter, and there were no physician orders for catheter care or monitoring. Nursing documentation failed to consistently record skilled assessments or urine output measurements related to the Foley catheter. Although some care plan interventions referenced catheter care if a catheter was in place, the plan lacked specificity and did not incorporate the hospital's discharge instructions or the resident's current infection and antibiotic regimen. Interviews with facility staff, including nurses, the administrator, and the DON, confirmed that the care plan was not individualized to the resident's needs and did not include essential information from the hospital discharge summary. Staff acknowledged that the lack of a resident-centered care plan and failure to document and implement catheter care could result in unmet care needs. The resident was ultimately hospitalized with a diagnosis of sepsis, and the facility's failure to provide a comprehensive, individualized care plan within the required timeframe was identified as the root cause of the deficiency.
Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
A deficiency occurred when a male resident with a history of hemiplegia, hemiparesis, cerebral infarction, and Wernicke's encephalopathy was admitted to the facility with an indwelling Foley catheter. Despite clear documentation from the hospital regarding the presence of the catheter and the need to prevent infection, the facility failed to obtain or document physician orders for catheter care, monitoring for signs and symptoms of infection, or monitoring of urinary input and output. The resident's care plan referenced catheter care interventions, but these were not supported by corresponding orders or consistent documentation in the medical record. Throughout the resident's stay, there was a lack of skilled nursing notes regarding catheter assessments or urine output measurements. Multiple progress notes and assessments referenced the presence of a Foley catheter, but there was no evidence of routine monitoring or documentation of catheter care. Interviews with staff revealed confusion and lack of recall regarding the resident's catheter status, and several staff members indicated that if catheter care was not documented, it likely was not performed. The absence of catheter care orders in the electronic medical record meant that necessary care tasks were not prompted or completed. The resident experienced multiple falls, confusion, and ongoing antibiotic treatment for a urinary tract infection. Ultimately, the resident was hospitalized and diagnosed with sepsis, with hospital records noting a distended bladder and recommendations to assess for catheter dysfunction. Interviews with facility staff and the resident's family confirmed that catheter care was not adequately managed, and the lack of orders and monitoring contributed to the resident's decline and hospitalization.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. Resident #1, who was cognitively intact and had a diagnosis of sepsis/osteomyelitis, was prescribed doxycycline to be administered twice daily. However, the medication was documented as administered at an incorrect time by LVN B. Similarly, Resident #2, also cognitively intact and diagnosed with multiple sclerosis and chronic kidney disease, was prescribed sulfamethoxazole-trimethoprim for a urinary tract infection. This medication was also documented as administered at an incorrect time by LVN B. Observations revealed that medication cups containing antibiotics for both residents were found unlabeled in a medication cart, and MA A, a medication aide, was instructed by LVN B to administer these medications, which she did not do. MA A stated she was trained to only administer medications she dispensed herself, and LVN B admitted to asking MA A to administer the antibiotics, which was against the facility's policy. Interviews with the residents indicated confusion about the administration of their medications, with Resident #1 recalling receiving medications from MA A and Resident #2 unsure about receiving her antibiotics. The Director of Nursing (DON) confirmed that the facility's policy required the person who dispenses the medication to administer it, emphasizing the importance of adhering to the 5 rights of medication administration. The facility policy also stated that medications should be administered within one hour of their prescribed time. The failure to follow these procedures resulted in a deficiency in pharmaceutical services, as the medications were not administered as prescribed, potentially placing residents at risk of medication errors.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to a resident. CNA A did not change her gloves after cleaning the resident's stool and proceeded to reposition the resident without changing gloves or performing hand hygiene. This lapse in protocol was acknowledged by CNA A, who admitted to not following the proper procedures despite having received training in infection control and incontinent care. Additionally, the facility did not ensure that CNA A and CNA B wore gowns during the provision of incontinent care to the same resident, who was identified as requiring enhanced barrier precautions (EBP) due to chronic wounds. Despite the presence of a sign indicating the need for gowns and gloves, and the availability of PPE outside the resident's room, both CNAs performed care without wearing gowns. They stated that they were instructed by the ADON to hurry and not wear gowns, although the ADON later denied giving such instructions. The resident involved had multiple diagnoses, including metabolic encephalopathy, pressure ulcers, and end-stage renal disease, and required maximum assistance for toileting and perineal care. The facility's policies on hand hygiene and EBP were not adhered to, as evidenced by the failure to use hand hygiene between glove changes and the omission of gown use during high-contact care activities. These deficiencies were observed despite the facility's training programs and policies designed to prevent the spread of infections.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) records. Resident #8, who was a smoker, had an annual MDS that inaccurately indicated no tobacco use. Despite having a comprehensive care plan and smoking assessment confirming the resident's smoking habits, the MDS nurse acknowledged the error, admitting that the question regarding tobacco use should have been answered affirmatively. Resident #14's MDS inaccurately recorded the use of anticoagulants, while the resident was actually taking Plavix, an antiplatelet medication, for cerebral infarction. The physician orders confirmed the absence of anticoagulant prescriptions, and the MDS nurse recognized the mistake, noting that the MDS should have reflected the correct medication class. Similarly, Resident #26's MDS inaccurately indicated the use of anticoagulants, despite no such medication being prescribed according to the physician orders. The MDS nurse admitted the error, acknowledging the responsibility for ensuring the accuracy of the MDS. These inaccuracies in the MDS assessments could potentially lead to inadequate care and services for the residents involved.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Specifically, the facility did not label or date open food items stored in the reach-in freezer, refrigerator, and dry storage. Additionally, strawberries stored in the walk-in cooler were found to have mold, and the temperature of the reach-in refrigerator was recorded at 60 degrees, which is above the acceptable range. These issues were identified during an observation of the kitchen, where four bags of open food were found unlabeled and undated, along with trays of dry cereal and cups with liquids that were also not labeled. The Dietary Manager acknowledged the responsibility of ensuring that all open food items are labeled and dated and that food items are not spoiled or moldy. The facility's temperature logs indicated that the reach-in refrigerator's temperature was recorded at 32 degrees during the AM shift, but the thermometer read 60 degrees during a later observation. The Dietitian confirmed that the temperature should be 41 degrees or lower and that the food in the refrigerator would be discarded due to the uncertainty of how long it had been over temperature. The facility's policy on refrigerator and freezer temperatures and food labeling was not followed, as evidenced by the lack of labeling and the improper storage temperatures. The U.S. FDA Food Code requires that refrigerated, ready-to-eat, time/temperature control for safety food be clearly marked with a date or day for consumption, sale, or disposal, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, Resident #22 was found in bed with the call light on the floor at the foot of the bed, out of reach. This was observed during a survey, and it was noted that the resident had a care plan intervention for the call light to be within reach to prevent falls. The resident, who had diagnoses including End Stage Renal Disease, Major Depression Disorder, and Atrial Fibrillation, was asleep and easily aroused, indicating she was tired from dialysis. The Director of Nursing (DON) confirmed the call light was out of reach and emphasized the importance of following the care plan, which is person-centered, to ensure residents receive proper care. The facility's policy on answering call lights also stated that call lights should be accessible to residents when in bed. The administrator acknowledged that the call light should be within reach to allow residents to alert staff when they need assistance, which could be critical in emergent situations.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding fall prevention measures. During an observation, it was noted that the resident, who had a history of falls and was care planned for fall prevention, was in a low bed without a fall mat next to it. This was contrary to the resident's care plan, which specified the use of a fall mat as an intervention to prevent falls. The resident, who had been diagnosed with End Stage Renal Disease, Major Depression Disorder, and chronic Atrial Fibrillation, was observed asleep in bed after returning from dialysis. The Director of Nursing confirmed the absence of the fall mat and acknowledged the importance of adhering to the care plan to provide proper care. The facility's policy emphasized the importance of making the environment free from accident hazards and ensuring interventions are implemented correctly and consistently.
Inadequate Incontinent Care for Uncircumcised Resident
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in preventing urinary tract infections and ensuring proper care for uncircumcised males. During an observation, CNA A did not return the foreskin of a resident to its original position after cleaning, which could lead to complications such as infection and paraphimosis. The resident, who has severe cognitive impairment and is frequently incontinent of bladder and always incontinent of bowel, was dependent on staff for most activities of daily living. The resident's care plan required checking every two hours and assisting with toileting as needed, including providing perineal care after each incontinence episode. Despite being trained and having completed a competency checklist for incontinent care, CNA A failed to follow the facility's policy and procedure for perineal care, which includes repositioning the foreskin of uncircumcised males. The Director of Nursing acknowledged the importance of this step to prevent potential complications.
Deficiency in Nursing Staff Competency During Incontinent Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, as evidenced by an incident involving CNA A during incontinent care for a resident. During the care, CNA A retracted the resident's foreskin to clean the penis but did not return it to its original position, which could lead to potential complications such as irritation, swelling, and infection. This incident was observed by surveyors and highlighted a deficiency in the competency of the nursing staff. The resident involved had a history of severe cognitive impairment, cerebral infarction, dysphagia, hemiplegia, hemiparesis, and dementia, and was dependent on staff for most activities of daily living. The facility's policy and procedure for perineal care required the repositioning of the foreskin after cleaning, which CNA A failed to do. Despite having completed a competency checklist for incontinent care, CNA A admitted to being nervous and not following the proper procedure, indicating a lapse in the application of her training.
Expired Thickened Water Found on Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper monitoring of expiration dates on medication carts. Specifically, the South unit medication aide cart contained a bottle of thickened lemon flavor water with high vitamin C that was expired. This expired product was observed on the cart, and the medication aide acknowledged its presence, stating that it had not been opened because no resident required it at the time. However, the aide kept it on the cart for potential future use with new residents, indicating a lack of awareness or oversight regarding the expiration status of the product. The Director of Nursing (DON) confirmed the presence of the expired thickened water on the medication cart and acknowledged that any expired medication or food product should be discarded. The facility's policy on the storage of medications requires that outdated or deteriorated drugs or biologicals be returned to the pharmacy or destroyed. The DON is responsible for ensuring that nursing staff check expiration dates, but this oversight was not effectively implemented, leading to the potential risk of residents consuming expired products.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel. During an observation, it was noted that a medication cart on the South unit was not properly secured, and a resident's 0.9% sodium chloride irrigation sterile water was left unattended on a nightstand in the resident's room. This oversight was confirmed through interviews with staff, including an LVN who acknowledged that medications should not be left in resident rooms unattended. Resident #3, who was involved in this incident, had a history of severe cognitive impairment and was totally dependent on others for activities of daily living. The resident's medical records indicated a need for regular catheter flushing with sterile water due to a history of urinary tract infections. Despite this, the sterile water was found unsecured in the resident's room, contrary to the facility's policy that requires all medications to be stored in locked compartments.
Failure to Provide Required Eating Utensils
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required them during meal service. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including intracranial injury, protein-calorie malnutrition, type 2 diabetes mellitus, dysphagia, and intellectual disabilities, was not provided with a built-up spoon as indicated on their meal ticket. The resident's care plan, initiated in November 2022, specified the need for a divided plate with a built-up spoon due to potential nutritional issues related to swallowing problems. However, during an observation on August 20, 2024, the resident was given a regular spoon instead of the required built-up spoon. Interviews with facility staff revealed that the nutrition service director acknowledged the resident was supposed to receive a built-up spoon to prevent potential swallowing problems. The kitchen staff could not find a built-up spoon for lunch, although one was provided for breakfast. An LVN confirmed that the meal ticket indicated the need for a built-up spoon, but the kitchen staff set up the lunch with a regular spoon due to the unavailability of the correct utensil. The facility's policy on assistance with meals, revised in March 2022, stated that adaptive devices should be provided for residents who need or request them, but this was not adhered to in this instance.
Failure to Maintain Safe and Functional Equipment
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically for one resident. The deficiency was identified when it was observed that the headboard of the resident's bed was loose and swinging up and down. This issue was noted during an observation on August 20, 2024, at 2:21 PM, when the resident was lying on the bed. The resident, who has a history of schizoaffective disorder, hypothyroidism, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and nicotine dependence, reported feeling a little uncomfortable due to the loose headboard but did not inform the staff, as he thought he was fine and was unaware of how long the headboard had been loose. Interviews conducted on August 21, 2024, with an LVN and a representative from Medical Record and Equipment confirmed the headboard's condition. The LVN acknowledged that the loose headboard could potentially cause the resident to fall. The Medical Record and Equipment representative admitted that it was their responsibility to ensure all medical equipment was safe and that no one had reported the issue with the resident's bed headboard to them. The facility's policy, revised in July 2017, emphasizes the importance of maintaining a safe environment free from accident hazards, highlighting that resident safety and supervision are facility-wide priorities.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as an elopement risk. The resident, who had a history of elopement and was assessed with moderate cognitive impairment, managed to leave the facility unsupervised. The resident was last seen in the smoking courtyard and was later found approximately 688 feet away from the facility at an intersection. The resident's care plan identified him as an elopement risk and included interventions such as monitoring for elopement-seeking behavior and redirecting him to other activities. Despite these measures, the resident was able to elope, indicating a failure in supervision and monitoring. The incident occurred when the resident was focused on obtaining another cigarette after his last allotted smoke break for the day, and staff attempted to redirect him to other activities. The facility's elopement protocol was initiated after the resident was discovered missing, involving an all-facility search and notification of the local police department. The resident was eventually found by the police and returned to the facility without injuries. The deficiency highlights a lapse in the facility's ability to monitor and supervise residents at risk of elopement effectively.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, and exploitation, leading to two residents eloping from the facility without staff knowledge. Resident #2, a male with severe disabilities and a history of behavioral issues, was able to exit the building and wheel himself to a bus stop on a city sidewalk. Staff were unaware of his exit-seeking behavior, which was documented in his admission paperwork. He was eventually brought back by police, but the incident highlighted a significant lapse in monitoring and security measures within the facility. Resident #1, a female with a history of drug abuse and homelessness, also managed to leave the facility without staff noticing. She was last seen walking towards the smoking courtyard but was later found to be missing during a medication round. Despite the facility's efforts to locate her, including contacting local hospitals and the police, her whereabouts remained unknown. This incident further underscored the facility's failure to adequately monitor and secure residents, particularly those with known risk factors for elopement. Interviews with staff and record reviews revealed that the facility did not have adequate alarm systems or monitoring protocols in place to prevent such incidents. The doors did not alarm or chime upon opening, and there were no cameras to monitor exits. Staff were also not adequately trained to recognize and respond to elopement risks, as evidenced by the lack of immediate action when residents were found to be missing. These deficiencies placed residents at significant risk of harm, highlighting the need for improved security measures and staff training to ensure resident safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, and exploitation, leading to two residents eloping from the facility without staff knowledge. Resident #2, a male with severe disabilities and a history of behavioral issues, was able to exit the building and wheel himself to a bus stop on a city sidewalk. Staff were unaware of his exit-seeking behavior, which was documented in his admission paperwork. He was eventually brought back by police, but the incident highlighted a significant lapse in supervision and monitoring by the facility staff. Resident #1, a female with a history of drug abuse and homelessness, also managed to exit the building without staff knowledge. She was last seen walking towards the smoking courtyard and was later found to be missing during the evening medication round. Despite the facility's efforts to locate her, including contacting local hospitals and the police, her whereabouts remained unknown. This incident further underscored the facility's failure to adequately supervise and monitor residents, particularly those with known behavioral issues. Interviews with staff and record reviews revealed that the facility did not have adequate measures in place to prevent such elopements. The doors did not alarm or chime upon opening, and there were no cameras to monitor exits. Additionally, the facility's policy on wandering and elopement was not effectively implemented, as evidenced by the lack of proper risk assessments and monitoring for residents with exit-seeking behaviors. These deficiencies placed residents at significant risk of harm, injury, or death.
Failure to Notify Physician of Low Blood Pressure Readings
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a change in condition and a need to alter treatment significantly for four residents. Specifically, residents were administered blood pressure medications when their blood pressures were low and outside of the physician-ordered parameters without physician notification prior to or after medication administration. This failure could result in decreased continuity of care and a delay in needed treatment and services. Resident #1, a female with diagnoses including metabolic encephalopathy, essential primary hypertension, and unspecified hypotension, was administered Losartan potassium despite having a blood pressure reading below the physician-ordered parameters. There was no documentation of the physician being notified of the low blood pressure reading or the administration of the medication outside of the ordered parameters. Similar issues were found with Resident #2, who was administered Metoprolol Tartrate with a low blood pressure reading, and Resident #3, who received Hydrochlorothiazide with a low pulse rate, both without physician notification. Resident #4, a male with diagnoses including end-stage renal disease, hypertensive heart disease with heart failure, and essential primary hypertension, was administered Losartan potassium and Carvedilol multiple times despite having blood pressure readings below the physician-ordered parameters. There was no documentation of the physician being notified of these low blood pressure readings or the administration of the medications outside of the ordered parameters. Interviews with the involved LVNs revealed inconsistencies in their practices and documentation regarding physician notification and adherence to medication administration parameters.
Significant Medication Errors Due to Administration Outside of Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, resulting in significant medication errors for four residents. These residents were administered medications to lower blood pressure even when their blood pressures or pulse rates were already low and outside the physician-ordered parameters. Specifically, the medications Losartan, Metoprolol, Hydrochlorothiazide, and Carvedilol were administered despite the residents having blood pressure readings below the specified thresholds, and there was no documentation of the physician being notified of these deviations from the prescribed parameters. Resident #1, a female with diagnoses including metabolic encephalopathy, essential primary hypertension, and unspecified hypotension, was administered Losartan despite having a low blood pressure reading. Similarly, Resident #2, diagnosed with cellulitis, essential primary hypertension, and legal blindness, received Metoprolol outside the ordered parameters. Resident #3, with diagnoses of unspecified dementia, essential primary hypertension, and heart failure, was given Hydrochlorothiazide despite a low pulse rate. Resident #4, a male with end-stage renal disease, hypertensive heart disease with heart failure, and essential primary hypertension, was administered both Losartan and Carvedilol outside the ordered parameters. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the facility had a system feature that allowed the use of the last documented vital signs for medication administration, which was later removed. The DON and LVNs stated that they manually took vital signs and did not use the copy feature, yet there was no documentation to support that physicians were notified when medications were administered outside the parameters. The Medical Director confirmed that he was not aware of these issues, and the lack of accurate vital sign documentation could complicate clinical decision-making.
Inaccurate Documentation of Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for seven residents, leading to potential risks for inaccurate health assessments and medication administration errors. Specifically, the blood pressures and vital signs for Residents #1, #2, #3, #4, #5, #7, and #8 were documented as the same on different shifts on the same day and on subsequent days. This inconsistency in documentation was observed across multiple records and dates, indicating a systemic issue in the recording process. For instance, Resident #1's EMAR showed identical vital signs recorded by LVN A on different shifts and days, and the same issue was noted for Resident #2, whose blood pressure and pulse were repeatedly documented as the same by different staff members. Similar patterns were observed in the records of Residents #3, #4, #5, #7, and #8, where blood pressures and pulses were documented identically across different shifts and days, despite the expectation that these values would vary. Interviews with staff, including the DON, LVN A, and CMA D, revealed that there was a feature in the computer system that allowed the use of the last documented vital signs, which may have contributed to the repeated entries. Although this feature was reportedly removed, the issue persisted, indicating a lack of adherence to proper documentation practices. The facility's policy on charting and documentation emphasized the need for complete and accurate records, which was not upheld in these instances.
Incomplete Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident with multiple complex diagnoses. The resident's care plan was incomplete and did not accurately describe his care needs. Specifically, the care plan did not address the resident's diagnoses of Frontal Lobe and Executive Function Disorder, Personality Disorder, Schizophrenia, Bipolar Disorder, and the acquired absence of both legs below the knee. The care plan only included minimal interventions for the resident's ADL self-care performance deficit, elopement risk, impaired cognitive function, risk for falls, and sedative/hypnotic therapy, without providing detailed and specific actions required to meet the resident's comprehensive care needs. During interviews, both the MDS Coordinator and the DON confirmed that the care plan was missing vital information necessary for providing proper care. The facility's policy on care plans, revised in March 2022, mandates that a comprehensive care plan should include a summary of the resident's medications, dietary instructions, and treatments to be administered by facility personnel. The failure to include all relevant diagnoses and detailed interventions in the care plan could lead to insufficient resident care.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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