Center At Zaragoza, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 12660 Pebble Hills Blvd., El Paso, Texas 79938
- CMS Provider Number
- 745005
- Inspections on file
- 18
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Center At Zaragoza, Llc during CMS and state inspections, most recent first.
An LVN independently removed a resident’s PICC line used for IV antibiotics, despite facility policy and Texas Board of Nursing guidance that only an RN may perform PICC insertion or removal. The resident, who had multiple cardiac conditions and moderate cognitive impairment, reported that the line was removed at the facility and denied pain or complications, and surveyors observed an intact, non-infected site. Documentation and staff interviews confirmed that the LVN performed the removal alone under a provider discontinue order, while the RN, ADON, DON, and Administrator all acknowledged that PICC removal is outside LVN scope and should be done by an RN.
A nurse failed to immediately notify a physician after observing blood-tinged urine and low output in a resident with a catheter. The issue was only reported to the physician after a family member raised concerns during the next shift, resulting in a delay in care.
A CNA did not perform proper hand hygiene or change gloves as required while providing incontinence care to a resident with multiple health conditions, including a history of UTI and bacteremia. The CNA wore gloves into the room, failed to change visibly soiled gloves, and did not wash hands before or after care, contrary to facility policy and infection control standards.
Three residents with significant physical or cognitive impairments did not have their call lights within reach, despite care plans and facility policy requiring this accommodation. Observations showed call lights on the floor or out of reach, and staff confirmed the deficiency and its risks. Residents were unable to request assistance as needed, relying on staff rounds or attempting to call out for help.
Two residents with severe cognitive impairment and multiple medical conditions did not receive proper assistance with fingernail care, resulting in dirty nails with visible debris. Staff interviews confirmed that nail care was the responsibility of nursing staff and CNAs, but there was no monitoring system in place to ensure this care was provided, despite facility policy requiring regular ADL assistance.
Staff failed to properly store and dispose of topical medications, leaving ointments in clear measuring cups exposed and accessible at the bedsides of two residents. Both residents required barrier creams for skin conditions, and staff interviews confirmed that medications should have been disposed of immediately after use. The facility did not have a policy for supervising or disposing of medications after administration.
Surveyors identified failures in food storage and sanitation, including unsealed containers of rice and soup, a torn bag of carrots, improperly sealed frozen turkey patties, a dirty container of tomato sauce, and undated frozen pastries. Staff interviews confirmed these practices did not follow facility policy, which requires all food to be sealed, cleaned, and dated to prevent contamination.
A resident receiving continuous oxygen therapy did not have an oxygen sign posted outside her room, despite staff and leadership acknowledging the importance of this practice for safety and monitoring. The facility lacked a written policy requiring oxygen signs, and the deficiency was confirmed through observation and staff interviews.
A resident with multiple medical conditions did not receive Megestrol Acetate as ordered for several days, and there was no documentation or rationale for the missed doses in the medical record. Staff interviews confirmed that medication aides and nurses did not follow procedures for documenting missed medications or notifying appropriate personnel.
A facility failed to implement a comprehensive care plan for a resident, omitting focus areas for bed rail use and the reassignment of a CNA involved in an incident. The resident, with anxiety and osteoporosis, had no care plan focus on bed rails despite an injury during care. Interviews revealed care plans did not reflect the resident's needs, risking inadequate care.
A resident in a long-term care facility was not assessed for the risk of entrapment from a bed rail before its installation, leading to an incident where the resident injured her wrist. The resident, who was dependent on staff for daily activities, did not have a Bed Transfer Bar Evaluation Assessment, and her care plans lacked a focus on bed rail use. Facility staff interviews revealed no policy for conducting such assessments, potentially placing residents at risk of injury from inappropriate enablers.
Two residents experienced breaches of privacy during personal care in the facility. A staff member failed to close blinds while weighing a resident, and a CNA left a room door open, exposing another resident's private area. Both incidents were acknowledged by staff, highlighting the need for privacy during care.
A facility failed to accurately reflect a resident's use of bed rails in the MDS assessment, despite orders indicating their use for bed mobility. The resident's care plans also lacked focus on bed rail use, and interviews with the DON and MDS Coordinator revealed a lack of awareness regarding the coding and associated risks. This oversight could risk inadequate care for the resident.
A facility failed to ensure a safe environment by not following proper procedures for using a mechanical lift. A staff coordinator weighed a resident using a mechanical lift without locking the brakes and without a second staff member, contrary to facility policy. The resident, with a history of falls and various medical conditions, required a Hoyer lift with two aides for transfers. The facility's policy mandates two staff members for mechanical lift use to ensure safety.
A resident with a Foley catheter was at risk for infection due to improper catheter care. The catheter bag was observed to be full, with urine backing up into the tubing, and the resident reported infrequent drainage by staff. Interviews with facility staff revealed a lack of adherence to catheter care protocols, including timely emptying of the catheter bag and reporting issues to nursing staff.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed improper food storage, expired food, and unclean food preparation areas. The Dietary Manager was observed without a beard guard, and there was no tracking system for cleaning tasks, placing residents at risk of foodborne illnesses.
The facility failed to develop and implement baseline care plans for three residents, leading to unmet dietary preferences, unaddressed diabetes management, and lack of necessary pressure reducing boots. Staff were unaware of critical medical needs, and residents were not involved in the care planning process.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs, including a tracheostomy, a vegetarian diet, and Type 2 Diabetes Mellitus.
A resident with severe osteoporosis and multiple fractures did not receive timely wound care for a knee wound, despite the facility's policy requiring comprehensive skin evaluations and adherence to treatment orders. The wound was first documented but not treated until several days later, with inconsistent care provided thereafter.
The facility failed to label a resident's enteral feeding formula bag with necessary information, risking incorrect feeding. The resident, who was on continuous feedings with Jevity 1.2 via a g-tube, had unlabeled feeding and water bags, which was confirmed by the LVN and DON.
LVN Removed PICC Line Outside Scope of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and adhered to the appropriate competencies and scope of practice for resident care, specifically related to the removal of a Peripherally Inserted Central Catheter (PICC) line. A male resident with chronic systolic congestive heart failure, chronic atrial fibrillation, ischemic cardiomyopathy with pacemaker, venous insufficiency, and a history of pulmonary thromboembolism was admitted and had an active care plan for completion of an antibiotic regimen via PICC line. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11. The care plan documented the use of a PICC line for antibiotic therapy, and the resident later reported that his PICC line had been removed at the facility a couple of weeks prior to the survey. On the date of the incident, a progress note completed by an LVN documented that the resident’s midline was discontinued per MD order using aseptic technique, with the catheter measured, tip intact, pressure applied, and a pressure dressing placed. The LVN documented that the resident tolerated the procedure well and was resting comfortably afterward. During interview, the resident confirmed that he had a PICC line that was removed at the facility, did not recall who was present during the removal, and denied pain or discomfort during or after the procedure. Observation of the site by surveyors showed no swelling, signs of infection, redness, or scabbing at the extraction site. Interviews with staff established that the LVN removed the PICC line independently, without RN presence or oversight, despite acknowledging that LVNs at the facility were only allowed to change PICC dressings and that PICC removal was not within LVN scope of practice. The LVN stated that RNs were responsible for pulling PICC lines and that removal required a provider order. The RN, ADON, DON, and Administrator each stated that only an RN could remove a PICC line per facility policy and Texas Board of Nursing standards, and that LVNs were not allowed to remove PICC lines. The ADON reported learning of the incident by reviewing progress notes and confirmed that the LVN had removed the line under discontinue orders from the NP, with no RN present. The DON confirmed she became aware that the LVN had removed the PICC line and informed the LVN that this was outside LVN scope of practice. Review of the Texas Board of Nursing position statement showed that insertion and removal of PICC lines or midline catheters is beyond the scope of practice for LVNs, confirming that the LVN practiced outside her scope when she removed the resident’s PICC line.
Failure to Immediately Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a nurse observed that a resident with a history of urinary retention and benign prostatic hyperplasia, who had an indwelling catheter, had red-tinged urine and low output during a shift. The nurse documented the finding and intended to notify the oncoming shift, but did not immediately inform the physician. The next shift was notified by a family member about continued issues with the catheter, including clots and dark red urine, at which point the physician was contacted and further interventions were ordered. Interviews with staff confirmed that changes in urine color and output should be promptly reported to the physician, and that it is the nurse's responsibility to ensure timely notification of any change in condition. The facility's policy also requires immediate physician notification for such changes. Documentation and staff statements indicated that the initial nurse did not follow this protocol, resulting in a delay in physician notification regarding the resident's change in condition.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a 73-year-old female resident with a history of urinary tract infection, bacteremia, abdominal pain, pancreatic cancer, and muscle weakness. The resident required moderate assistance with activities of daily living and was always incontinent of bowel and bladder. During observed care, CNA A did not wash her hands before donning gloves, put on gloves in the hallway, and proceeded to remove a soiled brief and clean the resident without changing gloves, even when the gloves became visibly soiled with urine and fecal matter. CNA A also failed to perform hand hygiene or change gloves before retrieving and applying a clean brief, and did not wash her hands after removing gloves or before exiting the resident's room. In interviews, CNA A acknowledged awareness of the correct procedures, stating she should have washed her hands before starting care and changed gloves during care, but attributed her failure to not paying attention. The Director of Nursing (DON) confirmed that staff are expected to follow facility protocols, including hand washing and glove changes as needed, and that infection control training is provided annually. Review of the facility's hand hygiene policy confirmed the requirement for hand washing before care, glove changes as needed, and hand hygiene after glove removal.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and the facility's own policy. Observations and interviews revealed that one resident was found lying in bed with the call light on the floor, out of reach and not visible to her. She stated she needed assistance to get out of bed and would have to wait for staff to check on her if she needed help, as she could not reach or see the call light. Another resident was observed in bed with the call light on the floor, three feet away, and he was unaware it had fallen. He stated he could not get up and would have to wait for staff rounds or try to shout for help in an emergency. A third resident, who was dependent for all self-care and unable to move independently in his wheelchair, was observed with the call light placed on the bed frame on the opposite side of the room, out of his reach. Staff interviews confirmed that the call light was not accessible to him and acknowledged the risk of injury or unmet needs when call lights are not within reach. Multiple staff members, including CNAs, RNs, the ADON, and the DON, stated that call lights are to be kept within reach of residents at all times, and that staff are responsible for monitoring their placement during regular rounds. Record reviews for all three residents showed significant physical and/or cognitive impairments, with care plans specifically directing that call lights be kept within reach to accommodate their needs and reduce fall risk. Despite these documented requirements and staff awareness, the facility did not ensure compliance, resulting in residents being unable to request assistance as needed. The facility's policy also required call lights to be within easy reach for residents in bed or confined to a chair, which was not followed in these cases.
Failure to Provide ADL Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the area of fingernail care, for two residents who required substantial or maximal assistance due to severe cognitive impairment and other medical conditions. Observations revealed that both residents had dirty fingernails with visible debris, and one resident expressed a desire for his nails to be cleaned and cut. Record reviews indicated that both residents had care plans and assessments documenting their need for assistance with personal hygiene, including grooming and nail care, due to diagnoses such as Alzheimer's disease, dementia, diabetes, and muscle weakness. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that nursing staff and CNAs were responsible for monitoring and providing nail care, with nurses specifically assigned to diabetic residents. However, it was acknowledged that there was no system in place to monitor or ensure that nail care services were consistently provided. Facility policy required assistance with ADLs, including grooming, every shift as appropriate, but this was not followed for the two residents identified in the report.
Failure to Secure and Dispose of Topical Medications at Bedside
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in locked compartments and only accessed by authorized personnel, as required. During observations, two residents were found to have clear measuring cups containing ointments left exposed and within reach at their bedsides. One resident had a cup with zinc oxide pomade and a tongue depressor, while another had a cup with an unknown pink ointment. Both items were accessible to other residents and had not been properly disposed of after use. Record reviews indicated that both residents had medical conditions requiring topical treatments, such as pressure ulcers and skin breakdown, with physician orders for the application of barrier creams. Interviews with staff, including CNAs, LVNs, RNs, and the DON, confirmed that the standard procedure was to apply the medication and immediately dispose of any remaining product. Staff acknowledged that leaving ointments at the bedside was not in accordance with facility protocols and could result in contamination or misuse. Further interviews revealed that staff could not recall recent training on medication storage and supervision, and the facility lacked a policy outlining procedures for supervising medications and disposing of them after administration. The failure to properly store and dispose of medications resulted in medications being left unattended and accessible at residents' bedsides.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food items. Specifically, containers of rice and chicken soup in the walk-in refrigerator were found with lids slightly open, and a bag of carrots was torn, exposing the contents to air. In the walk-in freezer, a bag of frozen turkey patties was not properly sealed, a container of frozen tomato sauce had dried drippings and residue around the lid, and bags of churros and donuts were undated. These observations were corroborated by interviews with the Executive Chef and a cook, both of whom confirmed that all food containers should be sealed, cleaned, and dated according to facility policy to prevent cross contamination and preserve freshness. The facility's Food Storage Policy requires all frozen food items to be properly sealed and dated, and fresh fruits and vegetables to be stored in bins, cartons, or bags. The staff interviewed acknowledged that the observed practices did not align with their training or facility policy, and that such lapses could result in food not being fresh or potentially contaminated. No specific residents or patient medical histories were mentioned in the report, and the deficiency was limited to the kitchen's food storage and sanitation practices.
Failure to Post Oxygen Sign for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of an oxygen sign posted outside the resident's room. The resident, a cognitively intact female with a history of asthma, COPD, or chronic lung disease, was observed receiving continuous oxygen via nasal cannula in her room. Despite the care plan specifying the use of supplemental oxygen and the need for monitoring, there was no visible indication outside the room to alert staff or visitors to the presence of oxygen therapy. Interviews with facility staff, including a CNA, LVN, DON, and the Administrator, confirmed that it was standard practice to post oxygen signs to notify others of oxygen use and potential hazards. However, it was revealed that the facility did not have a written policy requiring the posting of such signs. The lack of an oxygen sign was directly observed during the survey, and staff acknowledged the importance of this practice for safety and monitoring purposes.
Failure to Administer and Document Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident, resulting in missed doses of Megestrol Acetate over a two-day period. The resident, a cognitively intact female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, generalized anxiety disorder, muscle weakness, malnutrition, and anorexia, was admitted with an active order for Megestrol Acetate to treat loss of appetite. Review of the Medication Administration Record showed that the medication was not administered as ordered on three consecutive days, and there was no documented rationale for the missed doses in the resident's progress notes. Interviews with nursing staff and facility leadership revealed that medication aides are responsible for administering most medications, and are required to notify a nurse if a resident refuses medication or if a medication is not administered as ordered. Nurses are then expected to follow up with the resident, document the refusal or missed dose in the progress notes, and notify the physician and DON. However, in this case, there was no documentation of the missed doses or any follow-up actions in the resident's records, indicating a failure to follow established procedures for medication administration and documentation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of bed rails as enablers and the assignment of a CNA who was involved in a self-reported incident. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility and had an order for enablers to assist with bed mobility. However, the resident's care plan did not include a focus area for the use of bed rails, nor was it coded in the MDS section for restraints and alarms. Additionally, after an incident where the resident injured her wrist on a bed rail during care, the facility did not update the care plan to prevent the involved CNA from being assigned to the resident again. Interviews with the DON, MDS Coordinator, and Administrator revealed that the care plans were not accurately reflecting the resident's needs and risks associated with the use of bed rails. The DON acknowledged the absence of a focus area or intervention for bed rail use in the care plan, and the MDS Coordinator confirmed that the care plan should have addressed the incident involving the CNA. The lack of a comprehensive care plan could lead to residents not receiving necessary care or services tailored to their needs.
Failure to Assess Bed Rail Safety Risks for Resident
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from a bed rail prior to its installation. This deficiency was identified for one resident who was reviewed for the use of enablers, specifically bed rails. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility without a Bed Transfer Bar Evaluation Assessment to determine the appropriateness of the bed rails for her needs. Despite having a BIMS score indicating little to no cognitive impairment, the resident was dependent on staff for activities of daily living such as toileting and repositioning in bed. The resident's care plans did not include a focus area for the use of bed rails, and the facility lacked a policy for conducting Bed/Transfer/Bar Assessments. An incident occurred where the resident injured her wrist during incontinence care, reportedly hitting it on the bed rail. The injury was noted by an LVN, who observed swelling and tenderness in the resident's wrist. Although x-rays showed no fractures, the incident highlighted the absence of a proper assessment for the use of bed rails. Interviews with facility staff, including the Administrator and DON, revealed that there was no existing policy for Bed/Transfer/Bar Assessments, and the nursing staff were responsible for ensuring such assessments were completed. The lack of assessment and documentation could potentially place residents at risk of injury from inappropriate or unnecessary enablers.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to respect the personal privacy of two residents during personal care activities. For Resident #4, the Staff Coordinator did not close the room blinds while weighing the resident, which allowed others to see the care being provided. This oversight was confirmed by LVN C, who observed the situation and intervened by closing the blinds. The Staff Coordinator admitted to not closing the blinds, acknowledging the need to do so for the resident's dignity. Resident #4 had moderate cognitive impairment and was dependent on staff for various activities of daily living. For Resident #8, CNA A left the resident's room door open while retrieving incontinence care items, exposing the resident's brief and private area. CNA A acknowledged the importance of closing the curtain or door to maintain privacy during such care. The resident had a history of dementia and was dependent on staff for bed mobility and transfers. Interviews with the NP and DON confirmed that privacy should be maintained during incontinence care, emphasizing the moral obligation and training provided to staff.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the use of bed rails, also referred to as enablers. This deficiency was identified for one resident who was admitted to the facility with a history of anxiety and osteoporosis. The resident's admission orders included the use of bed rails to assist with bed mobility and control, yet the MDS did not reflect this use in Section P, which covers restraints and alarms. Additionally, the resident's baseline and comprehensive care plans lacked a focus area for bed rail use, despite the resident's dependence on staff for activities of daily living (ADLs) such as toileting and repositioning in bed. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed a lack of awareness and understanding regarding the coding of bed rails in the MDS. The DON acknowledged the oversight and expressed the need to review the risks associated with not coding the bed rails. The MDS Coordinator confirmed that the resident used bed rails but was not coded for them in the MDS, and was unsure of the risks involved. The facility's MDS policy mandates accurate completion and transmission of MDS assessments, yet this policy was not adhered to in this instance, potentially placing residents at risk of inadequate care.
Failure to Ensure Safe Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident. The incident involved a staff coordinator who was weighing a resident using a mechanical lift without locking the brakes and without the assistance of a second staff member, as required by the facility's policy. This action was observed by a Licensed Vocational Nurse (LVN) and confirmed during interviews with the staff coordinator and the Director of Nursing (DON). The facility's policy mandates that two staff members are required to operate a mechanical lift to ensure the safety of both the resident and the staff. The resident involved had a history of falls and was diagnosed with conditions such as Diabetes Type 2, right leg pain due to a fall, and ankylosing spondylitis of the thoracic region. The resident was dependent on staff for activities of daily living and required a Hoyer lift with two aides for transfers, as noted in the care plan. The staff coordinator admitted to not applying the brakes on the mechanical lift and acknowledged the risk of injury due to this oversight. The facility's mechanical lifts policy, dated February 2023, emphasizes the need for two staff members during the use of mechanical lifts to ensure safe patient handling and employee safety.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, leading to a risk of urinary tract infection. The resident, who was admitted with a history of diabetes and a severe ankle fracture, was observed with a catheter bag that was full of dark brownish urine, and the tubing contained a pink, cloudy substance. Despite the resident's ability to recall and make daily decisions, the catheter bag was not emptied in a timely manner, allowing the urine to back up into the tubing. This oversight was noted during an observation and interview with the resident, who reported that the nursing staff drained the catheter bag 3-4 times a day. Interviews with facility staff, including a CNA and the NP, revealed that the CNAs were responsible for checking and draining catheter bags at the end of each shift. The CNA acknowledged that a full catheter bag could cause reverse backflow, potentially leading to infection. The NP emphasized the importance of preventing full or cloudy tubing to avoid bacterial growth and UTIs. The DON confirmed that CNAs should report any issues with the catheter, such as sediment or discoloration, to the nurse and that catheter bags should be emptied when they are half full. The facility's Foley Catheter Policy mandates routine catheter care and notification of the DON/ADON for any issues, which was not adhered to in this instance.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed multiple instances of improper food storage and cleanliness in the kitchen. Food containers had accumulations of dried drippings and residue, and food preparation areas had dust, encrusted grease deposits, and other soiled accumulations. Additionally, food in the refrigerator was found with expired dates, and bananas were stored next to a dirty trash bin. The Dietary Manager was observed entering the kitchen without a beard guard, which was later corrected but not fully compliant as the mustache was not covered. Interviews with the Dietary Aide and the Dietary Manager confirmed the risks associated with these practices, including potential contamination and foodborne illnesses. The Dietary Aide acknowledged that residues on bottles and storing expired vegetables could lead to illness for the residents. The Dietary Manager admitted that using expired flour tortillas could pose a risk of bacteria growth and digestive infections. Furthermore, the kitchen had no tracking system in place to record when cleaning tasks were completed, and the grill, griddle, and deep fryer were found dirty with food residues and grease. The facility's policies and procedures on food storage, use of gloves/hairnets, and general sanitation of the kitchen were reviewed and found to be comprehensive. However, the observations and interviews indicated that these policies were not being followed. The lack of adherence to proper food safety and sanitation practices places residents at risk of foodborne illnesses, as confirmed by the Dietary Aide and the Dietary Manager.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents, which included necessary instructions to provide effective and person-centered care. Resident #35, who had severe osteoporosis and multiple fractures, was not provided with a baseline care plan that included her preference for a vegetarian diet. Despite her dietary needs being documented in her medical records and communicated to the dietary staff, the baseline care plan did not reflect this preference, leading to concerns about her nutritional intake and overall health. The dietary manager and dietitian were aware of her vegetarian diet but did not ensure it was included in the care plan, resulting in the resident relying on family members to supplement her diet. Resident #89, who had Type 2 Diabetes Mellitus with renal complications, did not have her diabetes management included in her baseline care plan. Her medical history indicated the need for monitoring blood sugar levels and insulin administration, but there were no orders or care plans addressing her diabetes. Staff members, including an RN and the MDS Coordinator, were unaware of her diabetes diagnosis, which led to a lack of necessary monitoring and treatment for her condition during her stay at the facility. Resident #192, who required pressure reducing boots as per physician orders, did not have this need included in his baseline care plan. Additionally, neither the resident nor his representative was involved in the care planning process or provided with a copy of the baseline care plan. The DON acknowledged the oversight and the risk it posed to the resident's care. The facility's policy required the development and implementation of a baseline care plan that reflects the resident's goals and needs, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #11, a female with multiple complex medical conditions including a tracheostomy, did not have her tracheostomy care included in her comprehensive care plan. Despite having orders for tracheostomy care, the MDS Coordinator missed including this critical aspect in the care plan, which could result in staff not identifying and addressing her care needs properly. The DON acknowledged that comprehensive care plans were not completed accurately due to a lack of training and stated that it was the MDS Coordinator's responsibility to complete them accurately. This oversight was confirmed by the MDS Coordinator, who admitted to missing the tracheostomy in the care plan, potentially leading to unaddressed care areas for the resident. Resident #35, who had severe osteoporosis and multiple fractures, had a preference for a vegetarian diet that was not included in her comprehensive care plan. Although her diet order and MAR indicated she was to receive a vegetarian diet, her care plan only mentioned maintaining her nutrition without specifying her dietary preference. The resident expressed concerns about not receiving a balanced diet and had to rely on family members to supplement her meals. The Dietary Manager and Dietitian were aware of her dietary needs, but the MDS Coordinator admitted that the resident's vegetarian preference should have been care planned to ensure the facility followed vegetarian guidelines. The lack of a specific care plan for her dietary preference posed a risk of not meeting her nutritional needs. Resident #89, who had Type 2 Diabetes Mellitus with kidney complications, did not have her diabetes care adequately addressed in her comprehensive care plan. Although her medical history and discharge instructions emphasized the need for monitoring her blood sugar, her care plan only mentioned risks related to skin breakdown and nutrition due to diabetes, without including blood glucose monitoring. The RN who worked with the resident was unaware of her diabetes diagnosis, and the MDS Coordinator admitted to not knowing about the diagnosis, which should have been care planned. The DON confirmed that the diabetes diagnosis should have been included in the care plan to ensure proper monitoring and availability of medications. This oversight could lead to unmonitored diabetic issues for the resident.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that Resident #35 received appropriate treatment and care for a wound on her left inner knee from 03/30/2024 to 04/09/2024. Despite the resident's medical history of severe osteoporosis, multiple fractures, and systematic lupus erythematosus, which put her at risk for wound healing complications, the facility did not provide the necessary wound care as per professional standards and the comprehensive person-centered care plan. The resident's baseline care plan did not identify any skin conditions at the time of admission, and the wound was first documented on 03/30/2024 but was not treated until 04/09/2024 when a physician's order was initiated for wound care treatment. However, the treatment was inconsistently provided, with several instances noted where wound care was not administered because the resident was asleep. Interviews and observations revealed that the resident was aware of the wound and reported that the facility did not address it until a physical therapist noticed it. The resident stated that the wound care nurse had difficulty locating her to provide treatment. The Director of Nursing (DON) could not explain the delay in wound care and acknowledged the risk of the wound worsening and potential infection due to the delay in treatment. The facility's policy required comprehensive skin evaluations and adherence to treatment orders, which were not followed in this case. The deficiency was identified through record reviews, interviews, and observations, highlighting the facility's failure to provide timely and appropriate wound care for Resident #35. This lapse in care could result in residents not receiving the necessary treatment for wounds, posing a risk to their health and well-being.
Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not label the enteral feeding formula bag with the resident's name, type of feeding, frequency, time, and date administration started. This deficiency was observed for one resident who was receiving continuous feedings with Jevity 1.2 via a g-tube. The lack of labeling could lead to the resident receiving incorrect feeding formula or an incorrect quantity of formula. The resident involved was [AGE] years old and had been admitted to the facility with diagnoses including diabetes and intractable nausea and vomiting. The resident was to receive nothing by mouth and was on continuous enteral feedings. During an observation, it was noted that the feeding formula bag and water bag hanging beside the resident's bed were not labeled. Interviews with the LVN and DON confirmed that the bags should have been labeled according to the facility's policy, but they were not. The DON was unable to provide documentation or a policy on labeling of enteral feeding bags before the survey exit.
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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