Castro County Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dimmitt, Texas.
- Location
- 1621 Butler, Dimmitt, Texas 79027
- CMS Provider Number
- 676186
- Inspections on file
- 44
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Castro County Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with schizophrenia, psychosis, PTSD, mild cognitive impairment, diabetes, and documented aggressive behaviors was issued a 30‑day discharge notice after a care conference determined her needs could not be met. The ADM reported that the signed discharge notice was given to the former BOM to send to the Office of the State LTC Ombudsman, but the Ombudsman later stated no notice was received, and the original signed notice could not be located. A policy governing this process was requested by surveyors but was not provided, resulting in a failure to ensure required Ombudsman notification of the 30‑day discharge.
Multiple residents experienced physical, sexual, and verbal abuse from peers, including incidents of groping, hitting, pushing resulting in injury, and verbal aggression. Some residents with known behavioral risks did not have adequate care plan interventions, and staff were unable to prevent repeated altercations despite behavioral health consultations and medication changes. The facility's failure to implement effective monitoring and supervision led to an Immediate Jeopardy situation.
Multiple residents with cognitive and behavioral impairments engaged in repeated physical, verbal, and sexual abuse toward other residents, resulting in injuries and distress. Despite staff awareness and some interventions, care plans were often incomplete or ineffective, and the facility failed to implement its policies and procedures to prevent and address these incidents.
Surveyors found that the facility did not develop or update care plans to address aggressive behaviors for multiple residents with documented incidents of physical and verbal aggression. Despite repeated episodes of resident-to-resident and resident-to-staff aggression, care plans were missing, outdated, or lacked specific interventions, leaving staff without clear guidance to manage these behaviors.
Staff failed to properly store hand sanitizer, resulting in a resident with severe cognitive impairment ingesting it and requiring hospital care. In separate incidents, two residents drank another resident's saliva from a spit cup in the dining room due to inadequate supervision. Staff interviews revealed a lack of training on handling ingestion of harmful substances, and care plans for at-risk residents were not effectively communicated or implemented.
The facility did not report multiple incidents of alleged abuse, neglect, or theft involving residents to the proper authorities within the required timeframe. These unreported events included physical altercations, inappropriate sexual contact, and actions resulting in serious injury, often involving residents with severe cognitive or psychiatric impairments. Review of records and incident logs confirmed that these incidents were not reported as mandated.
Surveyors observed that food items in the kitchen, refrigerator, dry pantry, and freezer were left open to air, unlabeled, undated, or improperly sealed. Items included cereals, chips, sandwiches, dairy, eggs, meats, and bulk pantry goods. These conditions were not in compliance with the facility's food storage policies, which require proper sealing, labeling, and dating of all food items.
Three residents with significant mobility and medical needs were found without access to their call lights, as the cords were left out of reach despite care plans and facility policy requiring otherwise. These residents, who could not get out of bed or use the bathroom independently, reported that staff did not consistently secure the call lights within reach, leading them to call out for help as staff passed by.
The facility did not ensure RN coverage for at least 8 consecutive hours daily over several months, resulting in a lack of RN oversight for high-acuity residents and staff such as LVNs and CNAs. Interviews with the ADON, DON, Corporate RN, and Administrator confirmed gaps in RN presence, incomplete documentation, and a lack of awareness regarding required RN staffing and supervision. Facility policy and state nursing regulations require RN oversight, but records and staff interviews indicated this was not consistently provided.
A resident with severe cognitive impairment and behavioral disturbances was not allowed to return to the facility after being hospitalized for psychiatric evaluation and treatment. Despite the facility's policy requiring residents to be permitted to return after hospitalization, leadership decided not to readmit the resident, citing safety concerns. The resident's belongings were removed and the room reassigned, and the required discharge procedures were not followed, as confirmed by staff, family, and the ombudsman.
A resident with a diagnosis of malignant neoplasm and a documented DNR order had a missing date on the DNR form, making it invalid. Staff interviews confirmed that the oversight could prevent honoring the resident's wishes, and the DON acknowledged the form was not properly checked for accuracy as required by facility policy.
Surveyors found that three resident rooms had environmental deficiencies, including large holes in the walls and peeling paint. Staff interviews confirmed that these issues had been present for at least two weeks, and the maintenance supervisor acknowledged missing some of the damage during rounds. The DON stated that such conditions do not meet facility policy for a safe and comfortable environment.
Two residents with orders for specific oxygen flow rates did not consistently receive oxygen therapy as prescribed, with one receiving higher and the other lower oxygen levels than ordered. Staff interviews confirmed that oxygen settings were not always checked or adjusted according to physician orders, leading to deviations from the care plan and facility policy.
A resident with a history of PTSD and other mental health diagnoses did not receive a trauma-informed care assessment upon admission, and his care plan lacked documentation or interventions related to his trauma. Staff interviews confirmed the required assessment was not completed, leaving staff unaware of the resident's triggers and needs, despite facility policy mandating such assessments.
Two residents with severe cognitive impairment were moved from a secured unit to the general population, but their care plans and physician orders were not updated to reflect this change. Staff and family interviews confirmed the move, yet the medical records continued to indicate the residents were in the secured unit, resulting in inaccurate documentation.
A CNA did not perform required hand hygiene before and during incontinent care for a resident with multiple chronic conditions, including dementia and diabetes. The CNA entered the room without washing hands, coughed into her hand, donned gloves without hand hygiene, and handled wipes and the resident's skin, leading to contamination. Hand hygiene was only performed after glove removal, contrary to facility policy and training.
A 10-foot section of handrail between two rooms in the memory care unit was found to be loose, with both screws in the middle bracket not properly secured. The maintenance staff acknowledged missing the issue during daily rounds, and the DON confirmed that handrails should be secure. During observation, several residents, including one using the handrail for mobility, were present in the area. Facility policy requires all handrails to be firmly secured and maintained by the maintenance department.
A facility failed to update a care plan for a resident with bipolar disorder, anxiety, and depression, despite these conditions being documented in admission records and the MDS. The care plan lacked goals and interventions for these diagnoses, even though the resident was receiving medication for them. Interviews with the DON, ADON, and MDS LVN confirmed that the care plan should have included this information, highlighting a lapse in ensuring comprehensive care planning.
A resident was mistakenly given 100 units of insulin glargine instead of the prescribed 11 units by an LVN, despite the resident's medical history of type 2 diabetes mellitus. The error was self-reported by the LVN, and the resident was monitored at the hospital and upon return to the facility. The facility's policies on medication administration were not followed, leading to this significant medication error.
A resident with dementia and other health issues was found unresponsive and transferred to the hospital without the facility notifying the family or physician. The LVN on duty did not inform the family due to a chaotic situation and shift change. The facility's policy requires prompt notification of significant changes, which was not followed.
A facility failed to implement its abuse prevention policy when a CNA did not report a bruise found on a resident with dementia and other conditions. Despite the facility's protocol requiring CNAs to report new bruises to nurses, the CNA did not inform anyone, citing a lack of response from agency nurses. This oversight could risk continued abuse, as confirmed by interviews with staff, including the DON and ADON.
A resident's medical records were inaccurately documented, listing the wrong behavioral hospital on the admission record. Additionally, the facility failed to perform required daily skin assessments for three days following admission, as per their policy. This placed residents at risk for incorrect or omitted treatment.
The facility failed to employ a qualified Dietary Manager, as the current DM lacked the necessary certification and was not enrolled in a certification class. Interviews with the ADM and DON highlighted potential negative outcomes, such as weight loss and incorrect dietary orders for residents, due to the DM's lack of qualifications.
A facility failed to notify the LTC Ombudsman of a resident's discharge to another facility due to unmet needs. The resident, with severe cognitive impairment, was transferred without timely notification to the Ombudsman, as required by policy. Interviews revealed confusion among staff about notification responsibilities.
The facility failed to assist 11 residents in exercising their right to vote in the 2024 election. Despite residents expressing a desire to vote, staff did not provide necessary assistance or information. Interviews revealed a lack of communication and coordination among staff regarding voting rights, and facility policies on resident rights and voting were not effectively implemented, resulting in none of the residents voting.
The facility failed to provide a safe and homelike environment by not ensuring functional bathroom sinks for residents. A resident with Alzheimer's was without a sink for a week, while another resident with a brain injury washed hands in the toilet due to a broken sink. Additionally, sinks in three rooms were loosely attached, posing potential safety risks. Staff interviews revealed a lack of concern for these deficiencies, despite facility policies emphasizing the importance of sanitary facilities.
A resident with Alzheimer's and other conditions was found with a bruise on his left eye, which was not reported to the state agency within the required 24-hour timeframe. Despite an investigation by the facility's DON and ADON, the cause of the bruise remained undetermined. The facility's policy mandates immediate reporting of such injuries, but delays occurred due to ongoing investigations and assumptions of no immediate harm.
A facility failed to document a resident's concerns about a past administrator in the social services notes, despite the resident being cognitively intact and having a history of mental health issues. Interviews with staff revealed that the incident was not documented, which could lead to staff being unaware of the resident's status. The facility's policy requires accurate and complete documentation, and the lack of it placed residents at risk for incorrect or omitted treatment.
A facility failed to coordinate assessments with the PASRR program, resulting in a deficiency for a resident with multiple disabilities. The required NFSS form was not submitted to the HHSC PASRR Unit by the deadline, due to a lack of communication and administrative oversight. The resident, with cerebral palsy, major depression, epilepsy, and cognitive communication deficit, did not receive the necessary PASRR Level II evaluation.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Multiple instances of improperly labeled and dated food items were found in various storage areas, which could lead to food contamination and potential foodborne illness among residents. Interviews confirmed that staff were responsible for following the facility's policy on safe food storage.
The facility failed to provide a homelike environment and manage noise levels during dining times, leading to a diminished quality of life for several residents. Observations revealed that rooms in the locked unit lacked personal belongings and essential furnishings, and noise levels in the dining room were disruptive. Staff and administration acknowledged these issues, which were not addressed effectively.
The facility failed to store medications properly in the medication room refrigerator, with temperatures recorded outside the recommended range on multiple occasions. Insulins and Acetaminophen suppositories were affected, potentially compromising their effectiveness. The ADON and DON confirmed the issue, and staff education on proper temperature monitoring was planned.
The facility failed to ensure that a resident's DNR order was accurately completed, resulting in the resident being considered a full code despite his wishes. The ADON confirmed the DNR form was invalid due to missing information, and the DON acknowledged the oversight, which violated the resident's rights.
The facility failed to conduct a comprehensive and accurate assessment of a resident, as the admission MDS did not list tobacco use despite the resident being a known smoker. The MDS Coordinator and DON acknowledged the error but believed it did not affect the resident's care since smoking was care planned.
The facility failed to assess and provide a communication board for a resident with severe communication deficits, impacting her ability to communicate needs and perform daily activities. Despite the resident's known preferences and ability to understand simple directions, no communication aid was provided, contrary to the facility's policy on accommodating individual needs.
The facility failed to maintain a hazard-free environment and provide adequate supervision, as evidenced by a space heater and cigarette lighter found in a resident's room and a Vape pen and cigarettes in another resident's room. Both residents had moderately impaired cognitive function, and the presence of these items posed significant fire and safety risks.
The facility failed to have an RN on duty for at least 8 consecutive hours on a specific day due to bad weather, leaving staff without supervisory coverage. The DON and ADM acknowledged the absence and the potential risks associated with this lapse.
Failure to Notify Ombudsman of 30-Day Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to notify and provide a copy of a 30‑day discharge notice to the Office of the State Long Term Care Ombudsman for a resident who was being discharged. The resident was a 59‑year‑old female admitted with paranoid schizophrenia, unspecified schizophrenia, delusional disorders, unspecified psychosis not due to a substance, post‑traumatic stress disorder, mild cognitive impairment, and diabetes. Her care plan documented risks for falls, behavioral issues, verbal and physical aggression, impaired cognition, and making false statements. A quarterly MDS showed a BIMS score of 15/15, indicating intact cognition. Incident reports documented that she had been the aggressor in hitting staff, throwing objects, refusing care, and making false statements, and she was described as delusional during her stay. An additional care conference was held where the resident was presented with a 30‑day discharge notice because the facility determined it could not meet her needs. Subsequently, the resident attacked a nurse, the police were called, a judge signed a warrant, and she was transported to a psychiatric facility. During interviews, the Ombudsman stated that no notice of the 30‑day discharge had been received. The administrator reported that the resident had been given the 30‑day notice at the care conference and that the signed notice was given to the former business office manager (BOM) to send to the Ombudsman. The administrator later learned the notice had not been sent and was unable to locate the original signed notice in the facility. A policy related to this process was requested by surveyors but was never provided. The facility therefore failed to ensure required notification of the 30‑day discharge was provided to the Ombudsman.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including physical, sexual, and verbal abuse, as well as neglect, as evidenced by multiple incidents involving resident-to-resident altercations. Nineteen residents were identified as victims of abuse or neglect, with documented events such as groping, slapping, pushing resulting in injury, hitting with objects, and verbal aggression. In several cases, residents with known histories of behavioral disturbances and severe cognitive impairment engaged in aggressive acts against other residents, and the facility did not have adequate interventions or care plan updates to address these behaviors. Specific incidents included a resident being groped by another resident, a resident being pushed to the floor resulting in a hip fracture, and multiple instances of residents being hit, punched, or verbally abused by peers. Some residents had care plans that acknowledged their potential for aggressive behavior, but interventions were either not effective or not sufficiently implemented to prevent further incidents. In other cases, residents with a history of aggression did not have care plans that addressed these risks at all. Documentation revealed that staff were sometimes unable to intervene in time to prevent abuse, and in some cases, residents were not separated or monitored closely enough to prevent repeated incidents. The facility's incident logs and progress notes showed a pattern of recurring altercations, with some residents being involved in multiple incidents over time. Despite behavioral health consultations and medication adjustments, aggressive behaviors persisted, and the facility did not consistently update care plans or implement effective monitoring and supervision. The survey identified an Immediate Jeopardy situation due to the ongoing risk of abuse and harm to residents, and the facility remained out of compliance pending evaluation of the effectiveness of corrective systems.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and exploitation for all 19 residents reviewed for abuse/neglect. Multiple incidents of resident-to-resident abuse occurred, including physical, verbal, and sexual abuse, as well as altercations resulting in injuries such as a fractured hip. The facility's own incident logs and progress notes document repeated episodes where residents with significant cognitive and behavioral impairments engaged in aggressive or inappropriate behaviors toward other residents. In several cases, care plans either did not address these behaviors or interventions were not effective in preventing further incidents. Specific events included a resident groping another, a resident slapping an unidentified peer, and several instances of residents physically assaulting each other with objects or by hand. In one case, a resident was pushed to the floor and sustained a hip fracture, while in another, a resident attempted to stab another with a fork. There were also episodes of verbal abuse, such as screaming and cursing, and repeated attempts by one resident to kiss other residents inappropriately. The documentation shows that staff were aware of these behaviors, and in some cases, attempted to intervene or notify medical and administrative personnel, but the actions taken did not prevent recurrence. The residents involved had complex medical and psychiatric histories, including severe cognitive impairment, dementia, schizophrenia, bipolar disorder, and other behavioral disturbances. Despite these known risks, the facility did not consistently update care plans to address aggressive or inappropriate behaviors, nor did it implement effective interventions to protect residents from harm. The failure to follow established policies and procedures resulted in multiple residents being subjected to abuse and physical harm, as evidenced by the facility's own records and staff interviews.
Failure to Develop and Implement Comprehensive Behavioral Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that accurately reflected the behavioral needs of multiple residents. Specifically, for 11 out of 14 residents reviewed, care plans did not address aggressive behaviors that were documented in progress notes and other records. In several cases, residents with histories of physical and verbal aggression towards staff and other residents did not have these behaviors reflected in their care plans, or the interventions listed were not updated to address recent incidents. For example, one resident with severe cognitive impairment and a history of aggressive outbursts, including physically harming other residents, had a care plan that was not revised to reflect these behaviors or to include specific, measurable interventions. Another resident with a diagnosis of schizophrenia and a documented incident of hitting another resident had no mention of aggressive behaviors in the care plan. Similar omissions were found for other residents with documented incidents of physical aggression, including pushing, hitting, and inappropriate sexual contact, none of which were adequately addressed in their respective care plans. The lack of updated and individualized care plans meant that staff did not have clear, actionable guidance to manage and prevent further aggressive incidents. The documentation showed repeated episodes of resident-to-resident and resident-to-staff aggression, with care plans either missing, outdated, or lacking specific interventions tailored to the residents' current behavioral needs. This failure to maintain accurate and comprehensive care plans was identified as a deficiency by surveyors, as it did not meet regulatory requirements for ensuring residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Prevent Resident Access to Hazardous Substances and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for several residents. Specifically, staff did not properly store hand sanitizer, resulting in a resident with severe cognitive impairment drinking an unknown amount of hand sanitizer and requiring hospital evaluation. The hand sanitizer was left accessible in the dining room, and staff interviews revealed uncertainty about who was responsible for its placement and a lack of knowledge regarding proper storage protocols. Multiple staff members, including CNAs, LVNs, and housekeeping, reported not receiving training on what to do if a resident ingests a harmful substance or chemical, and some were unaware of the incident or the resident's behavioral risks. In addition to the hand sanitizer incident, the facility failed to provide adequate supervision in the dining room, allowing two separate residents to drink the saliva of another resident from her spit cup. These incidents were not documented in the residents' progress notes or incident reports, and staff interviews indicated that these behaviors had occurred previously but were not consistently reported or addressed. The care plans for the involved residents identified behavioral risks, such as eating or drinking inedible items and aggressive behaviors, but interventions such as increased monitoring and 15-minute checks were not effectively implemented or communicated to all staff. Observations during the survey found hand sanitizer bottles stored in accessible areas, such as a shower room, and staff were unclear about official storage locations. Interviews with management and staff revealed a lack of consistent training and communication regarding hazardous substance management and resident supervision. The facility's failure to maintain a safe environment and provide adequate supervision placed residents at risk of harm, as evidenced by the ingestion of hand sanitizer and saliva by cognitively impaired residents.
Failure to Timely Report Alleged Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report multiple incidents of alleged abuse, neglect, or theft involving residents, as required by state law, within the mandated timeframe of no later than two hours after the allegation was made. The deficiency was identified through interviews and record reviews, which revealed that for 19 residents reviewed for abuse or neglect, none of the incidents were reported to the proper authorities, including the State Survey Agency. The events included physical altercations, inappropriate sexual contact, verbal aggression, and actions resulting in serious bodily injury, such as a resident being pushed to the floor and sustaining a broken hip. Specific incidents that were not reported included a resident groping another resident, slapping, punching, and attempting to stab with a fork, as well as residents engaging in mutual physical altercations. In several cases, the residents involved had documented histories of severe cognitive impairment, dementia, or psychiatric disorders, and their care plans often noted a risk for aggressive or inappropriate behaviors. Despite these known risks and the occurrence of actual incidents, the facility did not fulfill its obligation to report these events to the appropriate authorities in a timely manner. The deficiency was further substantiated by a cross-reference of the facility's incident log with the state reporting system, which confirmed that the incidents were not reported. Progress notes and care plans detailed the residents' medical and behavioral histories, the nature of the incidents, and the immediate actions taken by staff, such as notifying the DON or obtaining psychiatric consultations. However, there was no evidence that the required external reporting was completed for any of the incidents reviewed.
Failure to Store and Handle Food According to Professional Standards
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards, as evidenced by multiple observations in the kitchen, refrigerator, dry pantry, and freezer. Surveyors found several food items left open to air on kitchen countertops, including partial bags of cereal, chips, and thawed toaster waffles. In the refrigerator, numerous items such as servings of fruit cocktail, protein drinks, snack sandwiches, butter, jalapenos, lunch meat, cheese slices, iced tea, eggs, bacon, dough sheets, and whipped topping were found either uncovered, unlabeled, or undated. Some eggs had broken shells, and several items were open to air or lacked any indication of when they were received or prepared. In the dry pantry, a variety of food items including beans, refried beans, seasonings, pancake mix, croutons, food thickener, potatoes, pasta, muffin mix, and other packaged goods were found either open to air, unlabeled, undated, or covered in dust. Some items were past their expiration date, and many bulk or partial containers were not properly sealed. The freezer also contained numerous food items such as rolls, cinnamon rolls, ham chunks, dough sheets, biscuits, tater tots, bread, cookie dough, chicken breasts, potato wedges, meat pies, crab cakes, sausage, yellow squash, Philly steaks, chicken wings, and churros that were open to air, unlabeled, or undated. These findings were confirmed through interviews and a review of the facility's food storage policies, which require all food items to be properly sealed, labeled, and dated, and to follow first-in, first-out rotation. The dietary manager acknowledged that serving foods that are expired, unlabeled, undated, or left open to air could result in residents being served items that may cause illness or not meet nutritional needs. The facility's failure to adhere to its own policies and professional standards for food storage and handling was evident in the observed conditions.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences regarding call light placement for three residents. Observations revealed that these residents did not have access to their call lights while in bed, despite care plans specifying that call lights should be within reach and secured to their blanket or pillow. In each case, the call light cords were found hanging out of reach, either in the middle of the wall or behind furniture, preventing the residents from calling for assistance when needed. One resident, a male with moderate cognitive impairment and multiple diagnoses including dementia, chronic hepatitis C, and Wernicke's encephalopathy, was observed lying in bed with his call light cord approximately six feet away. He reported being unable to get out of bed or use the bathroom without help and stated that the call light had been out of reach for at least two days. He relied on calling out to staff as they passed by his room. Another resident, a female with diabetes, heart failure, and a large diabetic ulcer, was also found with her call light cord out of reach behind her nightstand. She reported not being able to get out of bed due to pain and stated that staff did not secure the call light within her reach during rounds. A third resident, a female with dementia, bacterial infections, and mobility issues, was similarly observed with her call light cord out of reach. She was unable to transfer herself or use the bathroom independently and expressed concern about wearing a brief for too long due to her medical history. Interviews with CNAs revealed inconsistent practices regarding the frequency of checking call light placement, with one CNA stating checks occurred every 15-30 minutes and another every two hours. Despite facility policy requiring staff to ensure call lights are within reach and secured, multiple observations confirmed ongoing failures to meet this standard for the affected residents.
Failure to Provide Required RN Coverage and Oversight
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Review of RN coverage hours revealed that there was no RN coverage for 8 consecutive hours on the majority of days across four months, specifically 30 of 31 days in January, 19 of 28 days in February, 20 of 31 days in March, and 20 of 30 days in April. This lack of RN coverage was confirmed through interviews and record reviews, with no documentation available to show that an RN was present or overseeing care during these periods. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), Corporate RN, and Administrator, revealed a lack of awareness and oversight regarding RN coverage. The ADON acknowledged the absence of an RN on many days and was unable to confirm if resident assessments had been completed or who had overseen the practice of Certified Nurse's Aides (CNAs) during this time. The DON stated that her hours were not recorded and could not confirm how staffing hours were reported for Payroll-Based Journal (PBJ) submissions. The Corporate RN was unaware of the lack of RN coverage and stated that no agency staff had been called to fill the gaps. The Administrator, new to her position, was also unaware of the RN coverage issue and could not provide documentation regarding oversight of CNAs or the use of agency RNs. Facility policy requires the use of a registered nurse for at least 8 consecutive hours per day, 7 days per week, and designates a registered nurse to serve as the DON on a full-time basis. The review of Texas Board of Nursing rules further clarifies the distinct roles and responsibilities of RNs and Licensed Vocational Nurses (LVNs), emphasizing that LVNs require appropriate supervision and cannot practice independently. The absence of RN coverage meant that resident assessments and oversight of care provided by LVNs and CNAs may not have occurred as required, and there was no documentation to support that these essential nursing functions were performed during the identified periods.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to establish and follow a written policy regarding the return of a resident after hospitalization, resulting in the refusal to allow a resident to return following evaluation and treatment at a psychiatric hospital. The resident in question was an elderly male with severe cognitive impairment, Alzheimer's disease, schizoaffective disorder, and a history of behavioral disturbances, including aggression and elopement risk. Documentation showed that the resident required moderate to total assistance with daily activities and had a care plan addressing his behavioral and safety needs. Progress notes detailed multiple incidents of aggressive and combative behavior by the resident towards staff and other residents, including physical altercations and attempts to elope. These behaviors led to the resident being transferred to a psychiatric hospital for further evaluation and treatment. While the resident was hospitalized, facility leadership, including corporate staff, decided not to permit the resident's return, citing concerns for the safety of other residents and staff. This decision was communicated to the ombudsman and the resident's family, and the resident's personal belongings were removed from his room, which was reassigned to another individual. The facility's own policy stated that residents should be permitted to return following hospitalization, and that not allowing a resident to return constitutes a discharge, requiring appropriate notice to the resident and their representative. However, the facility did not follow this policy, as the resident was not allowed to return and the required discharge procedures were not followed. Interviews with staff, family, and the ombudsman confirmed that the decision not to readmit the resident was made at the corporate level, and that the facility was aware this action could be considered an improper discharge or "dumping."
Failure to Ensure Proper Completion of Advance Directive (DNR) Form
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, as evidenced by a missing date on a Do Not Resuscitate (DNR) form for one resident. Record review showed that the resident, who was cognitively intact and had a diagnosis of malignant neoplasm of the bronchus or lung, had a DNR order in his file that was signed by both the resident and the physician, but the date of the resident's signature was missing. The facility's policy required that advance directives be properly completed and recognized under state law, but this DNR form was not fully completed as required. Interviews with staff, including an LVN and the DON, confirmed that the missing date rendered the DNR invalid, and staff acknowledged that this oversight could result in the resident's wishes not being honored in an emergency. The DON stated that all staff, including herself, were responsible for checking DNR forms for accuracy during care plan meetings, but this particular form was missed. The facility's failure to ensure the DNR was properly completed could have led to the resident not receiving care in accordance with his wishes.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a comfortable and well-kept environment in three resident rooms (A2, A10, and F5). In room A2, a large hole was observed between the resident's bedside dressers, and in room A10, two large holes and a small hole for a TV cable were found between the bathroom and closet doors. Room F5 had a significant area of peeling paint at the head of a resident's bed. These deficiencies were observed during routine rounds and confirmed by staff interviews. The maintenance supervisor (MS) acknowledged the presence of the holes and peeling paint, noting that the holes could pose a risk if residents, particularly those from the memory care unit, put their fingers in them. The MS also stated that the damage in room F5 had been missed during rounds and was caused by beds scraping the wall during care activities. Staff interviews revealed that the holes in rooms A2 and A10 had been present for at least two weeks, and the CNA did not report them, assuming the MS was aware due to frequent room checks. The DON stated that the facility should be clean, well-maintained, and free of holes or peeling paint, as such conditions could allow pests or present risks to residents. Facility policy requires a safe, clean, comfortable, and homelike environment, but the observed conditions did not meet these standards.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice and physician orders for two residents who required oxygen therapy. For one resident with multiple diagnoses including cerebral infarction, heart failure, and asthma, the care plan and physician order specified oxygen at 2 L/min via nasal cannula. However, repeated observations showed the resident receiving oxygen at 3 L/min, and at one point, a nurse found the oxygen set at 2.5 L/min, which was higher than the ordered amount. The nurse acknowledged the discrepancy and adjusted the oxygen flow to the correct setting. Another resident with diagnoses such as dementia, chronic respiratory failure with hypoxia, and COPD had a physician order for continuous oxygen at 3-5 L/min to maintain oxygen saturation above 90%. Observations revealed this resident was receiving oxygen at 2 L/min and 2.5 L/min at various times, which was below the ordered range. The resident was not aware of the prescribed oxygen levels and reported issues with oxygen tubing during transfers but did not mention concerns about the oxygen flow rate itself. Interviews with nursing staff and the DON confirmed that staff were expected to check and implement physician orders for oxygen therapy every shift and during transfers. The DON and nurses acknowledged that not following the prescribed oxygen settings could negatively affect residents, especially those with respiratory conditions. The facility's policy required oxygen to be administered according to physician orders and professional standards, but this was not consistently followed for the two residents identified.
Failure to Complete Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards. Specifically, a male resident with diagnoses including schizoaffective disorder, bipolar type, and post-traumatic stress disorder (PTSD) did not have a trauma screening or assessment completed upon admission, despite his documented history of trauma and PTSD. The resident's comprehensive care plan did not include documentation or interventions related to his PTSD, and there was no trauma-informed care assessment found in his clinical file. Multiple staff interviews confirmed that the trauma assessment was not completed as required, and staff were unclear about the resident's triggers and appropriate interventions. The resident, who is a veteran and attributed his PTSD to his military service, reported that he had not been offered any services related to his PTSD but expressed interest in receiving such services. Staff members, including the administrator, social worker, DON, and ADON, acknowledged that the trauma-informed care assessment should have been completed and recognized the importance of identifying triggers and needs for residents with trauma histories. The facility's own policy required a multi-pronged approach to identifying trauma history and cultural preferences, but this was not followed for the resident in question.
Failure to Update Medical Records Following Change in Resident Status
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for two residents who were no longer residing in the secured unit. Both residents had diagnoses including dementia and other cognitive impairments, and their care plans and physician orders continued to indicate that they resided in the secured unit, despite both having been moved to the general population. Observations confirmed that both residents were located outside the secured unit, and interviews with staff and family members corroborated that the residents' locations and care needs had changed. However, the medical records, including care plans and physician orders, were not updated to reflect this change. The Director of Nursing (DON) acknowledged that verbal orders had been given to move the residents out of the secured unit, but these changes were not documented in the residents' records. The Corporate RN also confirmed that the records were inaccurate and should have been updated when the residents were moved. The facility's own policy requires that each resident's medical record accurately represent their current status and care needs, but this was not followed in these cases.
Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper hand hygiene protocols while providing incontinent care to a resident. The CNA did not wash her hands upon entering the resident's room and coughed into her left hand before donning gloves without performing hand hygiene. During the care, the CNA used her gloved hands to handle wipes and assist with resident positioning, resulting in potential contamination of both the wipes and the resident's skin. Hand hygiene was only performed after glove removal at the end of the care episode, rather than at the required intervals. The resident involved was an elderly female with multiple diagnoses, including dementia, schizoaffective disorder, diabetes, atrial fibrillation, COPD, and muscle weakness. She required substantial assistance with toileting hygiene. The CNA acknowledged during interview that her actions led to contamination and that she had received hand hygiene training, though she could not recall when. The facility's policy and the Director of Nursing's expectations both required hand hygiene before resident contact, after contamination, and when moving from dirty to clean care tasks, which were not followed in this instance.
Loose Handrail Identified in Memory Care Hallway
Penalty
Summary
A deficiency was identified when a 10-foot section of handrail between rooms A8 and A10 was found to be loose during an observation. The handrail could be moved back and forth approximately half an inch, with both screws in the middle bracket noted to be loose. The maintenance staff (MS) acknowledged the loose handrail and stated that it had been missed during daily rounds, known as Angel Rounds. The MS was unaware of how long the handrail had been loose and confirmed that it was his responsibility to ensure the facility was well maintained. The Director of Nursing (DON) also confirmed that handrails should be secure and that maintenance was responsible for their upkeep. Further observations revealed that 12 residents were present in the main area of the memory care unit, with one resident using the handrail to pull himself in his wheelchair, another present with a walker, and two residents without assistive devices. A CNA working in the unit was unaware of the loose handrail and believed that residents, primarily in wheelchairs, would not be at risk of injury from the loose rail. Review of the facility's policy confirmed that all handrails are required to be firmly secured and that routine maintenance is the responsibility of the maintenance department.
Failure to Update Care Plan for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with bipolar disorder, anxiety, and depression. Despite the resident's admission records and quarterly MDS indicating these diagnoses, the care plan revised in February did not include any mention of these conditions or related goals and interventions. This oversight was identified during a review of the resident's records, which showed active medication orders for managing these mental health conditions, yet the care plan lacked corresponding documentation. Interviews with facility staff, including the DON, ADON, and MDS LVN, revealed that it was the responsibility of the nursing staff and MDS Coordinator to ensure care plans were updated and complete. The staff acknowledged that the resident's care plan should have included her mental health diagnoses and medication regimen. The absence of this information in the care plan could lead to staff being unaware of the resident's needs, potentially affecting the care provided.
Significant Insulin Administration Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of insulin. A resident, who was prescribed 11 units of insulin glargine, was mistakenly given 100 units by an LVN. This error occurred despite the resident's medical history, which included type 2 diabetes mellitus without complications, congestive heart failure, and hypertension. The resident's cognitive function was not impaired, as indicated by a BIMS score of 13 out of 15. The error was discovered when the LVN self-reported the incident to the Director of Nursing (DON). The resident was subsequently transported to the emergency room for evaluation, although she did not exhibit any symptoms of hypoglycemia and expressed feeling fine. The facility's investigation revealed that the LVN had documented administering the correct dose of insulin in the MAR/TAR, despite the error. The DON instructed the LVN to call 911, and the resident was monitored closely both at the hospital and upon her return to the facility. The facility's policies on medication administration and error prevention were not adhered to, as evidenced by the significant medication error. The policies outlined the importance of following the six rights of medication administration and ensuring medications are administered according to physician's orders. Despite these guidelines, the LVN administered an incorrect dosage, which could have jeopardized the resident's health and safety. The facility's response included an in-service on medication administration and the six rights, but the deficiency highlights a lapse in adherence to established protocols.
Failure to Notify Family and Physician of Resident's Hospital Transfer
Penalty
Summary
The facility failed to immediately inform a resident's family and physician when the resident was found unresponsive and transferred to the hospital. The resident, a male with a history of dementia, psychotic disorder, anxiety, Alzheimer's disease, and heart disease, was admitted to the facility and later found unresponsive in his room. Licensed Vocational Nurse (LVN) D did not notify the resident's family or physician when the resident was sent to the hospital via ambulance. The Assistant Director of Nursing (ADON) was informed by the emergency room nurse that the resident was being airlifted to a larger hospital, and the family was notified by the hospital, not the facility. Interviews with the resident's family revealed they were not contacted by the facility and only learned of the situation from the hospital. LVN E stated that it is the nurse's responsibility to notify the family and physician when a resident is transferred to the hospital. LVN D admitted to not notifying the family or physician due to the chaotic situation and shift change. The Director of Nursing (DON) and ADON both expected their nurses to notify the family and physician in such situations, but the notification did not occur. The facility's policy requires prompt notification of significant changes in a resident's condition, including transfers or discharges, which was not followed in this case.
Failure to Report and Document Resident Bruising
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the case of a resident who was admitted with multiple diagnoses, including dementia, psychotic disorder, and Alzheimer's disease. The resident's family member reported a large bruise on the resident's side upon his arrival at the hospital, which was not documented or reported by the facility staff. The facility's policy on abuse, neglect, and exploitation was not followed, as the Certified Nursing Assistant (CNA) who discovered the bruise did not report it to the nurse on duty. Interviews with various staff members, including CNAs and Licensed Vocational Nurses (LVNs), revealed that the facility's protocol required CNAs to report any new bruises or skin issues to the nurse immediately. However, the CNA who noticed the bruise on the resident's ribcage failed to report it, citing a lack of response from agency nurses. This inaction could place residents at risk of continued abuse. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the expectation for CNAs to report changes in residents' conditions, emphasizing the potential negative outcomes of not reporting injuries of unknown origin, which could lead to further harm or abuse.
Inaccurate Medical Records and Incomplete Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, which is a violation of accepted professional standards and practices. Specifically, the facility did not list the correct behavioral hospital on the resident's admission record, as the paperwork from the electronic health record (EHR) indicated a different hospital than what was documented. Additionally, the facility did not perform a skin assessment on the resident for three consecutive days following the initial admission skin assessment, contrary to the facility's Skin Assessment policy that requires daily assessments for the first four days. The resident in question was admitted with multiple diagnoses, including unspecified dementia with behavioral disturbance, psychotic disorder with delusions, generalized anxiety disorder, Alzheimer's disease with late onset, and atherosclerotic heart disease. The lack of accurate documentation and adherence to the facility's policies placed all residents at risk for incorrect or omitted treatment, duplicated treatments, and a failure to ensure continuity of care. Interviews with staff revealed a lack of awareness of the facility's policies, contributing to the deficiencies noted.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the Dietary Manager (DM) did not possess the necessary license, certification, or qualifications to function as the Director of Food and Nutrition Services. The DM, who was hired in April 2024 and assumed the role of DM in June 2024, admitted during an interview that she was not certified and was not currently enrolled in a certification class. She was waiting for corporate to facilitate her enrollment. The facility's policy requires that if a qualified dietitian is not employed full-time, a certified dietary manager should be designated to serve as the director of food and nutrition services. Interviews with the facility's administrative staff, including the Administrator (ADM) and the Director of Nursing (DON), revealed that the DM was not certified and that there were potential negative outcomes due to this deficiency. The ADM acknowledged that the DM would be taking classes soon, but no specific timeline was provided. The DON expressed concerns about the lack of training, which could lead to issues such as weight loss in residents and incorrect dietary orders. The ADM also noted that the absence of a certified DM could result in dietary requirements not being met, such as diabetic residents receiving inappropriate meals. The facility's policy emphasizes the importance of employing staff with the appropriate competencies to meet the needs of the resident population, which was not adhered to in this case.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for a resident who was transferred to a locked unit at another facility. The resident, an elderly female with severe cognitive impairment due to Alzheimer's disease, anxiety disorder, muscle weakness, and wandering, was discharged because the current facility could not meet her needs. The discharge occurred on December 11, 2024, but the Ombudsman was not notified until the following day, December 12, 2024. Interviews with facility staff revealed a lack of clarity regarding the responsibility for notifying the Ombudsman. The Administrator (ADM) acknowledged that it was her responsibility or that of a designee to ensure the Ombudsman was informed of transfers or discharges. The Director of Nursing (DON) was uncertain about whose responsibility it was to send the notices. The facility's policy requires that in cases of immediate transfer due to urgent medical needs, the notice must be provided as soon as practicable, which was not adhered to in this instance.
Failure to Assist Residents with Voting Rights
Penalty
Summary
The facility failed to ensure that 11 residents were able to exercise their right to vote in the 2024 election. This deficiency was identified through observations, interviews, and record reviews. Several residents expressed their desire to vote but were not provided with the necessary assistance or information to do so. For instance, one resident mentioned that they were not asked if they wanted to vote, and another resident stated that they were upset because they assumed they would be able to vote since they were registered. Interviews with staff revealed a lack of communication and coordination regarding the residents' voting rights. The Activity Director (AD) claimed to have spoken to residents about voting, but there was no documentation to support this claim. Additionally, the Social Worker (SW) and other staff members were not aware of any directives or training related to assisting residents with voting. The Director of Nursing (DON) acknowledged receiving an email about voting rights but did not take further action. The facility's policies on resident rights and voting were not effectively implemented. The policies stated that residents should be supported in exercising their rights, including voting. However, the facility did not ensure that residents were informed about upcoming elections or assisted with voter registration and absentee ballots. As a result, none of the residents were able to vote in the 2024 election, leading to feelings of being unheard and devalued among the residents.
Deficiency in Providing Safe and Functional Bathroom Facilities
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, specifically concerning the availability and security of bathroom sinks. Resident #1, who has Alzheimer's disease and severely impaired cognition, was without a sink in his bathroom for approximately a week. This lack of a sink posed a challenge for Resident #1, who required staff assistance for daily activities such as using the toilet and washing hands. Similarly, Resident #4, who has a traumatic brain injury and uses a wheelchair for mobility, was without a sink for an undetermined period. She resorted to washing her hands in the toilet basin, indicating a significant lapse in providing necessary sanitary facilities. Additionally, the facility failed to ensure that the sinks in Rooms A2, A7, and A9 were securely attached to the walls. Observations revealed that these sinks were loosely attached, with noticeable gaps between the sink and the wall, allowing them to move easily when touched. This situation could potentially lead to injury if a resident were to rely on the sink for support. The maintenance staff acknowledged the issue, noting that the sinks were designed to slide into brackets, which inherently made them loose, and suggested that pedestals might be needed for additional support. Interviews with facility staff, including the DON and ADON, revealed a lack of awareness and concern regarding the potential negative outcomes of residents not having securely attached sinks or any sinks at all. The staff did not perceive the absence of a sink as a significant issue, citing the availability of other sinks in common areas. However, the facility's policies on resident rights and maintaining a safe and homelike environment emphasize the importance of providing necessary sanitary facilities to prevent the spread of disease and ensure resident safety.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident within the required 24-hour timeframe to the State Survey Agency. The resident, a male with Alzheimer's disease, impulse disorder, prostate cancer, and anxiety disorder, was found with a dark purple bruise on his left eye. The injury was first noted by an LVN during a medication pass, and the resident was unable to explain how it occurred. Despite the injury being reported to the Director of Nursing (DON) and the Administrator, it was not reported to the state agency within the mandated period. The facility's staff, including the DON and Assistant Director of Nursing (ADON), conducted an investigation into the cause of the bruise but were unable to determine its origin. During the investigation, it was observed that the resident accidentally hit himself with a phone receiver, which was considered a possible cause of the injury. However, this incident occurred two days after the initial bruise was discovered. The facility's policy requires that injuries of unknown origin be reported immediately to administration and subsequently to the state agency within 24 hours, which was not adhered to in this case. Interviews with facility staff revealed a lack of immediate reporting to the state agency, as the DON delayed listening to the voicemail about the injury and subsequently notifying the Administrator. The DON and Administrator both acknowledged the delay in reporting, citing ongoing investigations and a belief that the resident was not in immediate harm as reasons for not reporting the injury within the required timeframe. This failure to report timely could place residents at risk of continued and/or unrecognized abuse or neglect.
Failure to Document Resident Concerns
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of concerns raised by the resident about a prior administrator. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of traumatic brain injury, schizoaffective disorder, bipolar disorder, anxiety disorder, major depressive disorder, and cognitive communication deficit. During a social services visit, the resident expressed concerns about a past employee, but these concerns were not documented in the social services notes. Interviews with facility staff, including the social worker, RN, ADON, and DON, revealed that the incident was not documented, which could lead to staff being unaware of the resident's status and the incident itself. The facility's policy requires that each resident's medical record accurately reflects their experiences and includes complete, accurate, and timely documentation. The lack of documentation in this case placed residents at risk for incorrect or omitted treatment and a failure to ensure continuity of care.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program, resulting in a deficiency for one resident. The facility did not provide the required Nursing Facility Specialized Services (NFSS) form to the Health and Human Services Commission (HHSC) PASRR Unit by the specified deadline. This oversight was identified during a review of the resident's clinical records and interviews with facility staff. The resident, a female with cerebral palsy, major depression, epilepsy, and cognitive communication deficit, was admitted to the facility and required a PASRR Level II evaluation due to her intellectual and developmental disabilities. However, there was no documentation of the necessary contact with the HHSC PASRR Unit, and the NFSS form was not submitted as required. Interviews with facility staff revealed that the former administrator may have mistakenly contacted the HHSC PASRR Unit, but did not inform the current staff, leading to the oversight. The MDS Coordinator, responsible for entering information into the PASRR portal, was unaware of any contact made on the specified date and acknowledged the facility's non-compliance due to management changes and other administrative issues. The facility's policy mandates coordination with the PASRR program to ensure residents with mental disorders or related conditions receive appropriate care, but this was not adhered to in this instance.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the kitchen, multiple instances of improperly labeled and dated food items were found. Specifically, various items in freezer 1, refrigerator 1, the kitchen counter, the condiment cart, and pantry 2 were observed without proper labels or dates. These items included bags of meat, squash, green beans, butter, cream, corn flakes, pasta, hoagie bread, sugar frosted flakes, tater tots, zucchini, scrambled eggs, meat patties, and spinach. This lack of proper labeling and dating could lead to food contamination and potential foodborne illness among residents. Interviews with the Administrator (ADM), cook E, FSA F, and FSA G confirmed that all kitchen staff were responsible for following the facility's policy on safe food storage. They acknowledged that improper food storage could result in contamination and food poisoning. A review of the facility's in-service training dated 3/16/23 indicated that staff had been trained on proper labeling and storage. Additionally, the facility's policy on food storage, revised on 6/1/2019, outlined the procedures for storing dry, refrigerated, and frozen foods, emphasizing the importance of labeling and dating all food items.
Failure to Provide Homelike Environment and Manage Noise Levels
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for several residents. Specifically, during dining times, the noise levels were disruptive, with residents yelling in frustration and other residents expressing discomfort with the noise. This issue was observed multiple times, and staff acknowledged that it was a common occurrence. Interviews with residents and staff confirmed that the noise levels in the dining room were disruptive and affected the residents' dining experience negatively. The administration was aware of the issue and had attempted interventions, but they were not effective in resolving the problem. Additionally, the facility did not provide adequate furnishings to promote a homelike environment for residents in the locked unit. Observations revealed that the rooms of several residents lacked personal belongings, decorations, and essential furnishings such as TVs. The rooms appeared institutionalized, with only a bed and a small dresser present. Interviews with staff and the administrator confirmed that the lack of personal items and furnishings could negatively impact the residents' condition, potentially increasing depression and boredom. The facility's policy on providing a safe and homelike environment was not followed, as evidenced by the lack of personal belongings and furnishings in the residents' rooms. The administrator and DON acknowledged that the current situation in the locked unit was not homelike and could affect both residents and staff. The facility's failure to create and maintain a homelike environment, as well as to manage comfortable sound levels during dining times, led to a diminished quality of life for the residents involved.
Improper Medication Storage in Medication Room
Penalty
Summary
The facility failed to ensure medications were stored in accordance with currently accepted professional principles in the medication room. The medication room refrigerator had documented temperatures that were out of the recommended storage range for several days in April 2024, with temperatures recorded at 32 degrees Fahrenheit and 30 degrees Fahrenheit on two separate days. This improper storage affected various medications, including Novolin R, Lantus, Novolin N, and Humulin insulins, which should not be frozen, and Acetaminophen suppositories, which should be stored at room temperature. The Assistant Director of Nursing (ADON) confirmed that medications stored outside the recommended temperature range would not be effective and should not be used. During an interview, the Director of Nursing (DON) also acknowledged that improperly stored medications would lose their effectiveness, potentially negatively impacting residents' conditions. The facility's policy and temperature logs indicated that refrigerator temperatures should be maintained between 36 and 46 degrees Fahrenheit, and any deviations should be addressed immediately. However, the night shift staff responsible for monitoring the temperatures were not available for further clarification. The ADON mentioned that all staff would be educated on proper temperature monitoring, including the night shift when available.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advanced directive, specifically a Do Not Resuscitate (DNR) order, for one resident reviewed. Resident #21, a severely cognitively impaired male with multiple chronic conditions, had a DNR in his record that was missing critical information in the Two Witness's Section and other required signatures. This incomplete documentation rendered the DNR invalid, which could lead to the resident receiving unwanted medical interventions contrary to his wishes or those of his legal representatives. During an interview, the Assistant Director of Nursing (ADON) confirmed that the DNR form for Resident #21 was not correctly filled out and therefore was not valid. As a result, the resident would be considered a full code, meaning that cardiopulmonary resuscitation (CPR) would be initiated if he were found without a heartbeat or respirations. The Director of Nursing (DON) acknowledged that the responsibility for ensuring the accuracy of DNR forms ultimately rested with her and admitted that the failure to complete the DNR process correctly violated the resident's rights. The facility's policy on resident rights regarding treatment and advanced directives was not adhered to, as evidenced by the incomplete DNR form in Resident #21's record.
Failure to Conduct Comprehensive and Accurate Assessment
Penalty
Summary
The facility failed to conduct a comprehensive and accurate assessment of a resident using the Resident Assessment Instrument (RAI) specified by CMS. Specifically, the admission Minimum Data Set (MDS) for a resident did not list tobacco use, despite the resident being a known smoker. This discrepancy was identified during a review of the resident's face sheet, baseline care plan, and safe smoking assessment, all of which indicated that the resident was a smoker. The MDS Coordinator acknowledged the error and stated that it would be corrected immediately, but believed that the error did not affect the resident's care or the facility's reimbursement since the smoking was care planned. The Director of Nursing (DON) confirmed that the resident had always been a smoker and had a history of drug addiction. The DON also stated that an inaccurate MDS could affect the facility's reimbursement but believed that the resident's care was not impacted because the smoking was care planned. The report highlights that the failure to ensure comprehensive and accurate assessments could place residents at risk for inaccurate and incomplete MDS assessments, potentially resulting in residents not receiving the correct care and services.
Failure to Provide Communication Aid for Resident with Severe Communication Deficits
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish. Specifically, the facility did not assess the needs of a resident with severe communication deficits for a communication board, which could have assisted her in effectively communicating with staff. The resident, who had diagnoses including Schizoaffective disorder, anxiety disorder, cognitive communication deficit, Dysarthria, anarthria, and Pseudobulbar affect, was observed struggling to communicate her needs using hand gestures. Despite the resident's ability to understand simple directions and her known preferences, such as TV channels and sports teams, no communication board was provided to her during the period reviewed. Interviews with the social worker and the Director of Nursing confirmed that a communication board would benefit the resident. The social worker mentioned that previous administration had attempted to use a communication board, but no such device had been used recently. The social worker also created a simple communication aid with pictures, which the resident used to indicate her feelings. The facility's policy on accommodating individual needs was not followed, as the resident's communication needs were not adequately assessed or met, potentially impacting her quality of life and ability to perform daily activities.
Failure to Maintain Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment remained free from accident hazards and that residents received adequate supervision. Specifically, a space heater was found in Resident #33's room, which was turned on and producing heat. Additionally, a cigarette lighter was found on Resident #33's bed. Resident #33, who has moderately impaired cognitive function, stated that a family member brought the space heater because he was cold and that he was allowed to have his lighter as he was an independent smoker. The facility's policy prohibits space heaters and lighters in resident rooms due to the risk of fire hazards. In another instance, Resident #40's room was found to contain a Vape pen and a carton of cigarettes on his bedside dresser. Resident #40, who also has moderately impaired cognitive function and a history of drug addiction, was not present in the room at the time of observation. The Vape pen and cigarettes were in plain view and accessible to other residents, posing a risk of accidental use or ingestion of unknown substances. The facility's policy requires that such items be removed to prevent potential harm. Interviews with staff, including CNAs and the ADM, confirmed that residents are not allowed to have space heaters, lighters, or Vape pens in their rooms due to the risk of fire and injury. The DON acknowledged that a family member might have brought the space heater for Resident #33 and confirmed that Resident #40's history of drug addiction made the presence of a Vape pen particularly concerning. The facility's policy on accidents and supervision emphasizes maintaining a hazard-free environment and providing adequate supervision to prevent accidents, which was not adhered to in these cases.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, on 02/11/2024, the facility did not have an RN on duty due to bad weather, which caused the scheduled RN to call in. The Director of Nursing (DON) confirmed that despite reviewing all staff and agency schedules, no RN was available to cover the shift on that day. This deficiency was identified during a review of the facility's RN coverage records for the last 90 days. Interviews with staff, including the DON and a Certified Nursing Assistant (CNA), highlighted the potential negative outcomes of not having an RN on duty, such as lack of supervisory coverage for coordination of events like hospice care, emergency care, and disaster response. The Administrator (ADM) also acknowledged the absence of RN coverage on the specified date and recognized the potential risks associated with this lapse in oversight. The facility's policy, implemented on 09/01/2023, mandates RN staffing for at least 8 consecutive hours per day, 7 days per week, which was not adhered to on 02/11/2024.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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