Coral Rehabilitation And Nursing Of Arlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 1112 Gibbins Rd, Arlington, Texas 76011
- CMS Provider Number
- 675112
- Inspections on file
- 70
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 51 (3 serious)
Citation history
Health deficiencies cited at Coral Rehabilitation And Nursing Of Arlington during CMS and state inspections, most recent first.
A resident with intact cognition and multiple diagnoses, including seizures and PTSD, had an active PRN order for Tylenol with Codeine #3 for pain, and the medication was found expired but still present on a hall medication cart. Staff, including an LVN, RN, ADON, and DON, reported they were unaware the drug was expired, despite stating that nurses and medication aides are responsible for checking for expired medications and that expired narcotics must be removed immediately for proper disposal. The facility’s medication storage policy required outdated medications to be immediately removed and destroyed, but this was not done, resulting in the expired narcotic remaining accessible on the cart.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A working call system was not available in each resident's bathroom and bathing area, as observed during the survey. This deficiency was noted based on the lack of required equipment to allow residents to request assistance in these areas.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
The facility did not have an infection prevention and control program in place, as observed by surveyors, resulting in a deficiency related to the lack of systematic infection control measures.
The facility did not coordinate assessments with the PASRR program and failed to refer residents for necessary services as required.
A resident with cerebral palsy, kidney failure, contractures, and dysphagia did not receive a comprehensive, person-centered care plan with measurable objectives and time frames, as required. The care plan called for physical, occupational, and speech therapy interventions, but there was no evidence that occupational or speech therapy were implemented or properly documented. Staff interviews revealed inconsistencies and a lack of documentation regarding therapy provision and refusals.
A resident with a Foley catheter did not receive the required monthly catheter change as ordered, with staff only changing the catheter bag and not the catheter itself. Documentation inaccurately reflected that the catheter was changed, and facility leadership was unaware of the missed change until questioned. The resident was dependent on staff and had multiple medical conditions, including neurogenic bladder and dementia.
A resident with multiple complex medical needs, including a tracheostomy and total dependence on staff, was found to have gnats present around his tracheostomy collar, nebulizer tubing, and a cloth with mucus drainage. Staff present were unaware of the cause and had not previously reported the issue, and the DON was not aware until informed. The facility's pest control policy was not effectively implemented, resulting in the resident's room not being free of pests.
Surveyors found that food items in the kitchen, refrigerator, and freezer were not properly labeled, dated, or stored according to facility policy and professional standards. Opened containers of rice, bread, chips, meat, and pudding were observed without required labeling or proper sealing. Dietary staff interviews confirmed that all staff were responsible for these tasks, but the required procedures were not followed.
Four shower rooms were found to be unclean and cluttered, with debris, used towels, opened bottles of cleanser, and unnecessary items such as a wheelchair and storage bins left inside. Broken and missing ceramic wall tiles were also observed, and staff confirmed that cleaning and maintenance protocols were not consistently followed, resulting in an environment that did not meet facility standards for cleanliness and safety.
A walk-in freezer was found with ice accumulation on the floor and a long icicle hanging from the ceiling vent, creating a slipping hazard. Staff interviews and record reviews indicated the issue had been ongoing for several months, with repeated documentation of ice buildup. The problem was known to both dietary and maintenance staff, but the underlying cause of the leak had not been fully addressed, resulting in continued unsafe and unsanitary conditions.
The facility failed to ensure accurate documentation of controlled medication administration, with multiple instances where narcotic medications were signed out on count sheets but not recorded on the MAR or in nursing notes. Several residents with complex medical histories and pain management needs were affected, as staff did not consistently follow required procedures for documenting PRN controlled medications. Staff interviews confirmed that documentation lapses occurred, primarily involving two nurses, and an internal audit revealed widespread inconsistencies between medication sign-out records and administration documentation.
The facility did not ensure that two shower rooms were kept clean and free of trash, soiled towels, used gloves, and other items, as observed by surveyors. Staff interviews confirmed that both CNAs and housekeeping were responsible for maintaining cleanliness, but the required standards were not met, resulting in unsanitary conditions.
Overhead light fixtures in several resident rooms across three halls were not functioning, resulting in lighting levels well below required standards. Two residents reported difficulty seeing in their room due to non-working fixtures, and staff acknowledged the issue and the lack of adequate lighting. Facility policy requires sufficient lighting to ensure a safe and comfortable environment, which was not provided in these areas.
A resident who was fully dependent on staff for ADLs due to paraplegia and other medical conditions did not receive scheduled showers or bed baths as required, with documentation and interviews revealing long periods without bathing, inconsistent care, and lack of supplies. The resident and family reported repeated requests for hygiene assistance, which were often unmet, and staff confirmed that scheduled baths were missed due to supply shortages and poor documentation.
A resident with multiple psychiatric and medical diagnoses had an incomplete MDS assessment that failed to document the use of high-risk medications, such as antipsychotics and anti-anxiety drugs, despite active orders and administration during the assessment period. The MDS coordinator did not code these medications due to frequent refusals by the resident, and the assessment was not properly reviewed or signed by clinical staff, resulting in an inaccurate reflection of the resident's care needs.
The facility failed to maintain an effective pest control program, leading to the presence of rodents and insects in the kitchen and resident rooms. Two residents reported seeing pests, and staff confirmed sightings of rodents in the kitchen and laundry areas. The pest control contract had been canceled due to slow payment, and the Administrator was unaware of this termination. The facility's pest control policy was not effectively implemented, resulting in a lapse in regular pest control measures.
A resident requiring tracheostomy care and continuous oxygen was at risk due to the absence of an extension cord needed for emergency power during outages. The facility staff, including the charge nurse and maintenance personnel, were unaware of the need for the extension cord and the status of emergency power outlets. The administration acknowledged the oversight, which posed a risk to the resident's safety despite the availability of portable oxygen and an ambu bag.
A facility's walk-in freezer had a leaking vent causing ice accumulation on the floor, creating a slipping hazard for kitchen staff. The issue persisted for six months without a formal maintenance log, relying on verbal reports. The administrator was aware of the problem only weeks before repairs were scheduled.
A resident with a history of stroke and dementia eloped from the facility and was found outside, combative and refusing to return. The police were called, and the resident was taken to the hospital. The facility failed to report the incident to the State Survey Agency, as the Administrator mistakenly believed a resident needed to be missing for 4-6 hours before reporting was necessary.
A resident with a neurogenic bladder and paraplegia did not receive proper catheter care, as their indwelling catheter drainage bag was left on the floor, contrary to facility policy. Staff interviews confirmed the risk of infection and the need for the bag to be secured to the bed frame, highlighting a deficiency in care.
A resident with a PICC line for antibiotic therapy was found with a peeling dressing, exposing the IV site. An LVN administered medication without addressing the compromised dressing, believing the line was functional. The facility's policy required dressings to be changed every 7 days or if compromised, but the LVN was unfamiliar with this policy. The ADON and DON acknowledged the risk of infection and the need for regular dressing checks.
The facility failed to address resident grievances, including a resident's complaint about the lack of hot water and multiple concerns raised during resident council meetings. Issues such as inadequate food portions, unresponsive staff, and pest problems were not documented or resolved, highlighting systemic issues in grievance handling.
Two residents with paraplegia and significant medical conditions did not receive scheduled showers due to a lack of hot water and inadequate documentation practices. The facility failed to use proper shower sheets for tracking and monitoring residents' bathing and skin conditions, leading to missed showers and unaddressed hygiene needs.
A resident with multiple pressure ulcers did not receive consistent wound care as ordered by the physician, leading to a decline in wound condition. The resident, who was dependent on staff for care, reported that his wounds worsened after a change in staff responsible for wound care. Facility staff interviews revealed inconsistencies in care provision and documentation, contributing to the deficiency.
The facility failed to provide a safe and comfortable environment on Hall 400 due to a non-operational water heater, affecting three residents who lacked hot water for personal hygiene. Interviews revealed resident dissatisfaction and discomfort, with one resident experiencing skin issues and another not being bathed for over a month. Staff were largely unaware of the issue, and despite obtaining bids for a new water heater, the facility had not resolved the problem.
A resident's Midline catheter dressing was not changed for 15 days, contrary to the facility's policy requiring changes every 5-7 days. The resident, in a persistent vegetative state, had no documented orders for dressing changes, increasing the risk of infection. Staff interviews revealed a lack of awareness and oversight regarding the dressing change schedule.
A resident in a persistent vegetative state did not receive Ketoconazole External Shampoo as ordered due to a lack of communication and documentation among staff. The shampoo was not available or applied as prescribed, placing the resident at risk of untreated conditions. The facility's policy required timely pharmacy services, but the deficiency was identified through record reviews and staff interviews.
Two residents in the facility did not receive appropriate treatment for their wounds due to a lack of awareness and documentation by the staff. One resident had multiple open ulcers on his leg that were not treated, while another had an autoimmune disease-induced wound that was not identified during regular skin assessments. The facility's failure to follow professional standards and care plans led to these deficiencies.
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. Spoiled tomatoes and carrots were found in the refrigerator, along with open bags of bacon and ham. The freezer contained open boxes of fish fillets and beef patties. Additionally, several containers of spices were open and exposed to air. The Dietary Supervisor acknowledged the responsibility of the dietary department for proper food storage, but deficiencies were still noted. A request for the food storage policy was not fulfilled.
The facility failed to deliver mail to residents on Saturdays, affecting their timely receipt of mail. A resident with multiple diagnoses, including anxiety disorder, reported not receiving mailed items. Staff interviews revealed inconsistencies in the mail delivery process, with mail being stored in a locked office until Monday unless a director was present to deliver it. The facility's policy required mail delivery within 24 hours, including Saturdays, but this was not followed.
The facility failed to inform residents and their representatives about grievance procedures, including how to file grievances and their rights to a written decision. Two residents with intact cognition were affected, with one reporting withheld grievance forms and another discharged after complaints. Staff provided inconsistent information on form availability, and the Administrator admitted to removing forms to prevent excessive use by a resident.
A resident with paraplegia was not provided a trapeze bar for repositioning in bed, despite having a physician's order from a previous facility. The resident, who was cognitively intact, had to rely on staff assistance for repositioning, as the facility was unaware of the need for a trapeze bar. Interviews revealed a lack of awareness among staff, and no relevant policy was provided by the facility.
Two residents experienced deficiencies in housekeeping and maintenance services, affecting their living environment. One resident had peeling wallpaper in his room, which had not been addressed since his admission. Another resident's room was inadequately cleaned, with dried spots and debris on the floor. Staff shortages and lack of communication contributed to these issues, impacting the residents' quality of life.
A resident was found with cigars and a lighter in their room, contrary to the facility's smoking policy requiring such items to be stored at the nurses' station. Additionally, hazardous items like razors and hand sanitizer were found unsecured in a unit accessible to residents. Staff were unaware of these items' presence, and no specific policy for hazardous item storage was provided.
Two residents experienced a lack of dignity and quality of life in the facility. One resident was not assisted out of bed for four months despite needing maximum assistance and expressing a desire to get up. Another resident wore a hospital gown due to a lack of personal clothing, affecting his self-esteem. The facility failed to address these issues promptly, impacting the residents' dignity.
A resident with a hip fracture and pressure ulcer was not assisted out of bed for four months, despite needing maximum assistance for transfers. Staff cited weakness and a previous fall as reasons, and the resident's care plan lacked provisions for getting out of bed. The resident was finally assisted using a Hoyer lift after staff began searching for appropriate equipment.
A resident with impaired cognition and wandering behaviors left a secured unit due to inadequate staffing. The Charge Nurse and CNA were off the unit, leaving the resident unsupervised. Staff reported difficulties in monitoring residents due to responsibilities in other areas, contributing to the incident. The facility's staffing policy was not effectively implemented, leading to insufficient supervision and a deficiency in care.
A resident received duplicate Bupropion therapy due to a medication error at the facility. The resident, with intact cognition and diagnoses of anxiety and depression, was prescribed Wellbutrin XL and later Bupropion HCl ER, leading to concurrent administration. The error was due to an LVN's oversight, and the facility lacked a specific policy for unnecessary medications.
A facility failed to maintain a medication error rate below 5%, resulting in a 15% error rate. An LVN did not administer Famotidine to a resident due to unavailability, while an MA failed to administer Baclofen, Pregabalin, and the correct dose of Colace to another resident. Additionally, a resident did not receive Flonase due to it being misplaced. Communication and procedural lapses contributed to these errors.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in the care of three residents. A resident with a hip fracture and pressure ulcer was not placed on enhanced barrier precautions, and staff were unaware of the need for such measures. Another resident with severe cognitive impairment and multiple medical devices also lacked appropriate precautions, with staff unfamiliar with the protocol. Additionally, an LPN failed to change gloves and perform hand hygiene during incontinence care for a resident, posing an infection risk. These lapses indicate a failure in implementing the facility's infection control policies.
A resident with a foley catheter did not have a catheter stabilization device, as required by facility policy, which could lead to urinary tract infections and urethral damage. The resident, with a history of hip fracture and Stage III pressure ulcer, was diagnosed with obstructive and reflux uropathy. The absence of the device was confirmed by the DON, despite conflicting accounts from the resident and an LVN.
The facility failed to maintain oxygen equipment for three residents, leading to outdated tubing and humidifiers, contrary to the weekly change policy. A resident with multiple health issues was not using her nasal cannula due to discomfort, while another required continuous oxygen but had outdated equipment. A third resident had undated tubing and no humidifier. Staff interviews revealed a lack of adherence to maintenance protocols, risking infection.
The facility failed to provide individualized and group activities for residents in the secure unit, as required by their care plans. Observations showed no structured activities, and residents were left without engagement, leading to increased risks of altercations and falls. Staffing challenges and the absence of a dedicated activity director for the secure unit contributed to this deficiency.
Two residents known for seeking alcohol and becoming intoxicated were inadequately supervised, leading to their unsupervised departure from the facility. One resident, with a history of mental health issues, frequently left without signing out, returning intoxicated and aggressive. Another new resident left through the back gate during a shift change and was found intoxicated by police. The facility's interventions and supervision policies were insufficient, resulting in residents leaving unsafely.
A facility was found to have a non-functional call light system in several halls, affecting residents' ability to call for assistance. Residents reported feeling abandoned and experienced significant delays in receiving help, with some waiting over two hours for essential care. Observations confirmed that call lights were not audible at nursing stations, leading to an Immediate Jeopardy situation.
A resident with paraplegia did not receive necessary care during the overnight shift, resulting in her leg hanging from the bed and becoming swollen. The resident was in distress and unable to call for help due to non-functional call lights. Staff were unaware of her presence on the new hallway, leading to a lack of regular checks. The facility's failure to address the call light issues and ensure regular checks placed the resident at risk of harm.
Expired PRN Narcotic Left on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically by not removing an expired Tylenol with Codeine #3 (acetaminophen-codeine 300-30 mg) tablet from a medication cart. A male resident with intact cognition (BIMS score of 15) and diagnoses including muscle weakness, anxiety disorder, depression, seizures, and PTSD had an active physician order for Tylenol with Codeine #3, one tablet by mouth every six hours as needed for pain. His care plan identified him as being at risk for alteration in comfort related to seizures and history of falls, with interventions including pain medications as ordered. During an observation of the 300 hall medication cart, surveyors found that this resident’s Tylenol with Codeine #3 had expired earlier in the month and remained available on the cart. Multiple staff interviews confirmed that nurses and medication aides were responsible for checking medications to ensure none were expired, and that expired medications, particularly narcotics, were to be removed from the cart immediately and given to the DON for proper disposal. LVN A, RN B, the ADON, and the DON each stated they were unaware that the resident’s Tylenol with Codeine #3 was expired and acknowledged that expired medications should not be present on the cart. The ADON and DON reported that ADONs audited medication carts weekly and the consultant pharmacist audited carts every other month. The facility’s Medication Storage policy, revised 10/2023, stated that outdated medications are to be immediately removed from stock and disposed of according to destruction procedures and reordered if a current order exists, which was not followed in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The absence of a working call system in these locations was directly noted during the survey, but no additional details about specific residents, their medical history, or their condition at the time were provided in the report.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in the report, and no additional details regarding individual medical histories or conditions at the time of the deficiency were provided.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Comprehensive Person-Centered Care Plan and Therapy Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a resident with multiple complex medical conditions, including cerebral palsy, kidney failure, contractures, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had significant communication and mobility limitations. The care plan indicated the need for habilitative physical and occupational therapy services, habilitation coordination, and independent living skills, as agreed upon by the family and local mental health authority. However, there was no evidence that the interventions for speech and occupational therapies were implemented as outlined in the care plan. Interviews with facility staff revealed inconsistencies and lack of documentation regarding the provision and refusal of therapy services. The DON initially reported that the resident was not receiving specialized services due to hospice status, but later confirmed that physical therapy had been provided and occupational therapy was pending approval. The Director of Rehabilitation stated that speech therapy was never recommended and believed the family declined it, but this refusal was not documented in the resident's electronic health record. The facility's policy required the interdisciplinary team to develop and implement a comprehensive care plan in conjunction with the resident and their representative, with explanations documented if participation was not practicable, but this was not followed in this case.
Failure to Perform Ordered Foley Catheter Change
Penalty
Summary
A deficiency occurred when a resident with a Foley catheter did not receive the required monthly catheter change as ordered by the physician. The resident, who had a history of stroke, diabetes, dementia, neurogenic bladder, and obstructive uropathy, was dependent on staff for mobility and had severely impaired cognitive skills. The physician's order specified that the Foley catheter should be changed every month on the 13th, and the care plan reflected this requirement. However, documentation by an RN indicated that the catheter was changed, but in reality, only the catheter bag was replaced due to leakage, and the catheter itself was not changed. Interviews with the RN and the DON confirmed that the catheter was not changed as ordered, and the DON was unaware of the missed change until questioned. The resident's family member also reported not observing a catheter change and was told conflicting information by staff. The facility's catheter care policy emphasized the importance of proper catheter management to reduce complications, but the required procedure was not followed for this resident.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident's room not being free of gnats. During an observation, a resident with significant medical needs, including a tracheostomy, supra-pubic catheter, colostomy, and quadriplegia, was found to have gnats flying around his tracheostomy collar, nebulizer tubing, and a cloth with mucus drainage on his chest. A cluster of gnats was also observed on the cloth and flying around the room. The resident was dependent on staff for all activities of daily living and was non-verbal at the time of the observation. Staff present during the observation, including a CNA and an LVN, were unaware of the cause of the gnats and indicated that maintenance would be notified. The Director of Nursing was not aware of the issue until informed during the interview. The Maintenance Director confirmed he was notified about the gnats and subsequently cleaned the room, but stated that no prior reports had been made regarding the presence of gnats in the resident's room. Review of facility policy indicated a requirement for an effective pest control program, which was not effectively implemented in this instance.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage and handling practices during their review of the kitchen. In the dry food pantry, a large plastic container of rice was found without a label or date, and opened bags of potato and tortilla chips were wrapped in plastic wrap but not dated or properly stored according to facility policy. In the refrigerator, two opened bags of bread were not labeled, dated, or properly stored; a container of white gravy was covered with plastic wrap that had a large hole; chopped meat and an opened pack of deli meat were not labeled or dated; and a large bowl of chocolate pudding was uncovered and not labeled or dated. In the walk-in freezer, an opened bag with meat patties, two opened packs of hamburger buns, and a large roll of ground beef were all found without labels or dates. Interviews with dietary staff and the dietary manager confirmed that all kitchen staff were responsible for labeling and dating food items, and that opened or unused products should be placed in sealed containers or bags, labeled, and dated. The dietary manager, who had only been at the facility for three days, acknowledged the need for staff education on proper labeling and dating. Facility policies reviewed by surveyors required that all perishable and bulk foods be covered, labeled, and dated, and that leftover and refrigerated foods be stored in covered containers, clearly labeled and dated, and used within specified timeframes. These requirements were not followed, as evidenced by the observations and staff interviews.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in four of six shower rooms reviewed (100, 300, 400, and 500 halls). Observations revealed that these shower rooms contained various forms of debris, such as used towels, dirty gloves, overflowing wastebaskets, and opened bottles of skin and hair cleanser left out in the open. Additionally, several broken and missing ceramic wall tiles were noted in each of the affected shower rooms. Unnecessary items, including a wheelchair, hangers, pillows, and empty plastic storage bins, were found stored in the 300 hall shower room. These conditions were confirmed through interviews with staff, who acknowledged that shower rooms should be cleaned after each use and that supplies should be properly stored. Staff interviews further indicated that the facility's maintenance and cleaning protocols were not consistently followed, as items were left out and repairs to the shower rooms had not been completed. The facility's policies require that residents be provided with a safe, clean, and homelike environment and that maintenance services be provided to all areas of the building. However, the observed conditions in the shower rooms did not meet these standards, as cleanliness and order were not maintained, and necessary repairs were not completed.
Failure to Maintain Safe and Sanitary Walk-In Freezer Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the walk-in freezer, as evidenced by the presence of small pieces of ice and two large chunks of ice on the floor, along with a long icicle hanging from the ceiling vent. Observations confirmed the accumulation of ice, and interviews with the Dietary Manager (DM) and Maintenance Director (MTD) revealed that the issue had been ongoing, with documentation in the Registered Dietician's notes of repeated ice accumulation on the floor over several months. The DM, new to the facility, was unaware of the duration of the leak, while the MTD acknowledged the persistent problem and described efforts to break up and clean the ice as it formed. The facility's Maintenance Service policy requires that all areas, including equipment, be maintained in a safe and operable manner and free from hazards. Despite this, the walk-in freezer continued to have ice accumulation due to a leaking vent, which was known to both the maintenance and administrative staff. The issue was recognized as a hazard by staff, with the potential for injury due to slipping and falling on the ice, but the underlying cause had not been fully resolved at the time of the survey.
Failure to Accurately Document Administration of Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, there were inconsistencies between the documentation of narcotic medications signed out on the narcotic count sheets and the documentation of those medications administered as reflected on the Medication Administration Records (MAR) and nursing progress notes. This deficiency was identified for five residents who were reviewed for pharmacy services, all of whom had orders for controlled pain medications such as Tramadol, Tylenol with Codeine, and hydrocodone/APAP. In multiple instances, medications were signed out on the control drug records but not documented as administered on the MAR or in the nursing notes, and vice versa. The residents involved had varying degrees of cognitive impairment and complex medical histories, including conditions such as hypertension, stroke, dementia, chronic pain, and other comorbidities. For example, one resident with severe cognitive impairment and multiple diagnoses had Tramadol signed out on the control drug record on several dates, but the MAR and nursing notes did not reflect administration of those doses. Similar discrepancies were found for other residents, with controlled medications being signed out but not documented as given, or lacking corresponding nursing notes to support administration. Interviews with residents indicated that they generally felt their pain was managed, but the documentation did not support that medications were administered as ordered. Staff interviews revealed that nurses were required to count controlled medications at shift changes and document administration on both the MAR and narcotic count sheets. However, some staff admitted to missing MAR entries, often due to distractions, and recognized the importance of proper documentation for communication and assessment purposes. The Director of Nursing and other staff identified that two nurses were primarily responsible for the documentation failures, and an internal audit confirmed multiple instances of incomplete or missing documentation for PRN controlled medications. The facility's policies required accurate and timely documentation of medication administration, but these procedures were not consistently followed, resulting in the identified deficiency.
Failure to Maintain Clean and Homelike Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in two of five shower rooms reviewed (300 and 500 halls). Observations revealed soiled washcloths and towels left on the shower rack and floor, a gallon of liquid body soap in the shower area, a black duffel bag on the floor, and used gloves and a hanger on the floor and under the shower chair. These items were not removed or cleaned up as required, resulting in unsanitary conditions in the shower rooms. Interviews with staff, including CNAs, housekeepers, the DON, and the administrator, confirmed that both CNAs and housekeeping staff were responsible for ensuring the cleanliness of the shower rooms. Staff acknowledged that the presence of trash, soiled towels, and other items in the shower rooms was not acceptable and could lead to infection or harm to residents. The facility's policy required a clean and homelike environment, but this standard was not met in the observed shower rooms.
Inadequate Lighting in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on three of five halls reviewed for environmental concerns. Specifically, overhead light fixtures in multiple resident rooms across the 200, 300, and 400 halls were not functioning properly, resulting in inadequate illumination. Observations and interviews revealed that in several rooms, some or all overhead fixtures did not work, and residents reported difficulty seeing in their rooms. Lighting measurements taken in these rooms showed levels significantly below the required 50-foot candle standard, with readings ranging from 19.6 to 30.5 foot candles at approximately 30 inches above the floor. Staff interviews confirmed awareness of the inadequate lighting, with the maintenance director acknowledging the outdated fixtures and the ongoing but incomplete efforts to update them. The administrator and DON recognized that low lighting could impact resident safety and visibility. Review of facility policy indicated a requirement for comfortable and adequate lighting in all areas to promote a safe and homelike environment, which was not met in the affected rooms.
Failure to Provide Scheduled Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, for a resident who was dependent on staff for all ADLs and mobility due to multiple medical conditions, including paraplegia, osteomyelitis, pressure ulcers, heart failure, hypertension, and diabetes. The resident's care plan indicated a self-care performance deficit and required staff to provide sufficient time and encourage the use of the call bell for assistance. Despite this, documentation in the electronic health record and shower sheets showed that bathing activities frequently did not occur as scheduled, with long gaps between baths and only a few instances of bed baths or showers being provided over a period of several weeks. Interviews with the resident revealed that he had only received three to four bed baths since admission and had never been in the shower. The resident reported repeatedly requesting baths, but staff often gave excuses such as lack of hot water or towels. The resident's family corroborated these statements, noting that they had to provide personal hygiene wipes and assist with hygiene during visits due to the facility's lack of supplies and inconsistent care. The resident expressed feelings of shame, discomfort, and frustration as a result of not receiving regular baths. Staff interviews confirmed that the resident was scheduled for regular showers but did not always receive them due to supply shortages, particularly towels. CNAs reported that the resident did not refuse care, and one CNA noted that the resident was always thankful when a bath was provided. The DON acknowledged that staff were expected to document all showers and refusals, but found that documentation was inconsistent and could not provide records of refusals as claimed. The facility was unable to produce a policy on ADL care when requested.
Failure to Accurately Reflect High-Risk Medication Use in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected the resident's status, specifically regarding the use of high-risk medications. The quarterly Minimum Data Set (MDS) assessment for a male resident with multiple psychiatric and medical diagnoses did not document the use of high-risk medications, such as antipsychotics and anti-anxiety drugs, that were prescribed and administered to the resident. The MDS assessment was incomplete and had not been reviewed or signed by the appropriate clinical staff at the time of the survey exit, with only the social worker and dietary manager having signed it. Record reviews showed that the resident had active orders for Olanzapine and Buspirone, both considered high-risk medications, and these were administered on several occasions during the assessment period. However, the MDS coordinator did not code these medications in the MDS because the resident had refused them on most days within the 7-day look-back period. The MDS coordinator stated that if the medication was not administered during the look-back period, it would not be coded, despite the resident having a history of mood and behavioral issues and being prescribed these medications. Interviews with the MDS coordinator, DON, and Administrator confirmed that the expectation was for the MDS to accurately document all high-risk medications, current treatments, and care needs. The facility's policy, based on the RAI Manual, requires documentation of high-risk drug classes if the resident is taking them during the last 7 days. The failure to accurately reflect the resident's medication use in the MDS assessment was identified as a deficiency, as it could lead to incomplete care planning and lack of appropriate monitoring for the resident.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents and insects in both the kitchen and resident rooms. Two residents were directly affected by this deficiency. One resident, who is cognitively intact and uses a wheelchair due to paraplegia, reported seeing large water bugs and small roaches in his room. He had previously complained about the issue, but no action was taken. Another resident, also cognitively intact, reported seeing rats in his bathroom during maintenance work. He mentioned that his cats often reacted to sounds in the walls, indicating a persistent pest problem. The facility's pest control program was found to be inadequate, as the contract with the pest control service provider had been canceled due to slow payment, with the last service provided in mid-December 2024. Staff interviews revealed that rodents were seen in the kitchen and laundry areas, with one staff member observing a rodent on dish racks and having to disinfect the dishwasher due to rodent droppings. Despite these observations, the Kitchen Manager denied seeing any rodents, although he acknowledged the risk of sickness and disease to residents. The facility's Administrator was unaware of the termination of the pest control contract and had not seen pest control staff at the facility. The facility's pest control policy outlined measures for pest prevention and monitoring, but these were not effectively implemented. Staff reported seeing bugs and rodents, but there was a lack of consistent action to address these sightings. The facility's pest control visit log confirmed that the last service was provided in early February 2025, indicating a lapse in regular pest control measures.
Failure to Ensure Emergency Power for Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required tracheostomy care and continuous oxygen. The deficiency was identified when it was observed that an extension cord, necessary for maintaining the resident's oxygen supply during a power outage, was missing from the resident's room. The resident, who had a tracheostomy and was dependent on continuous oxygen, was at risk due to the lack of proper emergency power arrangements. The resident's care plan specified the need for an extension cord to connect to emergency power outlets, but this was not adhered to. The deficiency was further compounded by a lack of awareness and training among the staff. The charge nurse, who was relatively new to the facility, was unaware of the need for an extension cord and had not received training related to power outages. Additionally, the maintenance staff, including the Maintenance Director and Maintenance Aide, were not fully informed about the status of the emergency power outlets and the necessity of the extension cord in the resident's room. The Maintenance Director, who was also new, was unaware that the red outlet in the resident's room was not connected to the emergency generator, which led to a misunderstanding about the power supply's reliability. The facility's administration, including the Administrator and the Director of Nursing (DON), were also not fully informed about the electrical issues and the need for the extension cord. The Administrator acknowledged the responsibility for ensuring the extension cord was available and that staff were trained on emergency procedures. The Medical Director confirmed that the outlet should not have been red if it was not connected to emergency power, and noted that the plan for the extension cord had been previously addressed. Despite the availability of portable oxygen and an ambu bag, the lack of a reliable power source for the resident's oxygen concentrator and compressor posed a risk to the resident's safety.
Walk-in Freezer Leak Creates Hazard in Kitchen
Penalty
Summary
The facility failed to maintain a safe and functional environment in the kitchen's walk-in freezer, where water was observed dripping from a vent onto the floor, creating a slipping hazard. This issue was identified during an observation on February 26, 2025, where ice was found accumulating on the floor and under a shelf. The Kitchen Manager reported that the leak had been ongoing for about six months and had been verbally communicated to the previous maintenance director and the administrator. The administrator acknowledged awareness of the leak only a few weeks prior and had arranged for repairs, which were confirmed to be scheduled for the same day as the observation. Interviews with the Maintenance Director and Maintenance Aide revealed that there was no formal maintenance log for reporting issues, and the staff relied on verbal communication and a group chat for maintenance requests. The Maintenance Director was only made aware of the issue on February 26, 2025, and confirmed that a company was addressing the problem. The lack of a formal reporting system contributed to the delay in addressing the leak, which posed a risk of slips and falls for the kitchen staff. The facility's sanitization policy, revised in December 2008, requires that the food service area be maintained in a clean and sanitary manner, which was not upheld in this instance.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the State Survey Agency as required by state law. The resident, who had a history of cerebral infarction, Bell's Palsy, and dementia, was admitted to the facility with additional diagnoses including atrial fibrillation and coronary artery disease. On the night of the incident, the resident, who was known to wander with an unsteady gait, eloped from the facility. The resident was last seen walking the hall before being found outside, combative and refusing to return. The police were called, and the resident was taken to the hospital for further evaluation. Interviews with facility staff revealed that the resident was not considered exit-seeking by family members, and the Director of Nursing (DON) was unsure how the resident managed to elope. The Administrator did not report the incident, mistakenly believing that a resident needed to be missing for 4-6 hours before it warranted reporting. The facility's policy required that any allegations of abuse, including elopement, be reported within specified timeframes, which was not adhered to in this case.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder, leading to a deficiency in care. The resident, a male with a neurogenic bladder, paraplegia, and a stage 4 pressure ulcer, was dependent on staff for toileting. Observations revealed that the resident's indwelling catheter drainage bag was left on the floor, which is against the facility's policy and clinical guidelines. The catheter was not anchored to a non-moveable part of the bed, increasing the risk of urethral tears, dislodgment, and urinary tract infections. Interviews with staff, including LVN A and the DON, confirmed that the catheter bag should not be on the floor and should be secured to the bed frame. LVN A acknowledged the risk of infection but did not address the issue promptly, leaving the drainage bag on the floor for an extended period. The facility's policy emphasizes the importance of anchoring indwelling catheters to prevent excessive tension and potential complications, which was not adhered to in this instance.
Failure to Maintain Intact PICC Line Dressing
Penalty
Summary
The facility failed to ensure the proper care and maintenance of a PICC line for a resident, leading to a deficiency in intravenous care. The resident, a male with a history of sepsis, neurogenic bladder, paraplegia, a stage 4 pressure ulcer, and hypertension, was observed with a PICC line dressing that was peeling off, leaving the IV site exposed. Despite this, an LVN administered an IV antibiotic without addressing the compromised dressing, as she believed the line was functioning properly since it flushed without resistance. The facility's policy required PICC line dressings to be changed every 7 days or as needed if the dressing was not intact. Interviews revealed that the LVN was not familiar with the facility's PICC dressing policy and believed that LVNs were not supposed to change PICC line dressings. The ADON confirmed that the dressing was coming off and needed to be changed, emphasizing the risk of infection and the potential for the PICC line to become dislodged. The DON stated that nurses were expected to check the dressing every shift and during every antibiotic administration, highlighting the primary risk of infection associated with PICC lines. The facility's policy also indicated that dressings should be changed if they were wet, dirty, or compromised in any way.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances, as evidenced by the lack of documentation and follow-up on resident complaints. Resident #2, a male with paraplegia and other significant health issues, reported the absence of hot or warm water in his room, which affected his hygiene and comfort. Despite filing a grievance, there was no documented attempt to resolve his issue, and the maintenance director was aware of the broken water heater but was waiting for approval to repair it. Additionally, the facility did not address grievances raised during resident council meetings in December 2024 and January 2025. Concerns included inadequate food portions, unresponsive staff, noise disturbances, and pest issues. These grievances were not documented or resolved, leaving residents' concerns unaddressed and potentially impacting their quality of care. Interviews with facility staff revealed systemic issues in handling grievances. The social worker and activity director had unclear roles in documenting and resolving grievances, leading to a lack of follow-up and communication with residents. The administrator acknowledged the importance of addressing grievances but did not ensure a consistent process for tracking and resolving them, resulting in unresolved resident concerns.
Failure to Provide Scheduled Showers and Maintain Hygiene Documentation
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, two residents, both with paraplegia and other significant medical conditions, did not receive showers or bed baths as per the facility's bathing schedule. Resident #2, who had paraplegia, pressure ulcers, and required assistance for bathing, reported not having hot or warm water in his room or the shower at the end of his hall, resulting in missed showers on two scheduled occasions. Resident #3, also with paraplegia and pressure ulcers, had not been bathed or showered in the past week and could not recall the last time he had been bathed, with no hot or warm water available in his bathroom. The facility's records and interviews revealed that there were no shower sheets for the two residents for January 2025, and the staff had not been using the appropriate shower sheets to document bathing and skin observations. The Assistant Director of Nursing (ADON) confirmed the absence of shower sheets and acknowledged that the current system of using a list for the charge nurse to sign off was inadequate. The ADON and other staff members, including CNAs, were unaware of the proper documentation process, which led to a lack of monitoring and tracking of residents' bathing and skin conditions. Interviews with staff indicated a lack of awareness and adherence to the proper procedures for documenting showers and skin observations. The facility's administration was informed of the issue when a family member of one of the residents raised a concern. Despite requests, the facility's policy on ADL care related to showers was not provided during the survey, indicating a possible gap in policy communication or availability.
Inconsistent Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary wound care for a resident with multiple pressure ulcers, as ordered by the physician, on several occasions in December 2024 and January 2025. The resident, who had a history of paraplegia and chronic ulcers, did not receive the prescribed wound care for his sacrum and heel on specific dates, which was not documented or explained in the nursing progress notes. This lack of consistent care was noted to have potentially contributed to the worsening of the resident's wounds. The resident, who had intact cognition and was dependent on staff for activities of daily living, reported that his wounds had almost healed under the care of a previous ADON but deteriorated after the ADON left. During December 2024, the floor nurses were responsible for wound care due to the absence of a designated wound care nurse, but the resident reported inconsistencies in care. The resident's representative also expressed concerns about the decline in wound condition and the lack of consistent care. Interviews with facility staff revealed that the wound care nurse, who started in January 2025, was responsible for wound care during weekdays, while charge nurses handled it on weekends. However, there were still gaps in care, as indicated by the resident's complaints and the lack of documentation for missed treatments. The facility's policy required documentation of wound care, but this was not consistently followed, contributing to the deficiency.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on Hall 400. The water heater supplying heat to three resident rooms and the shower room on Hall 400 was not operational, resulting in the absence of hot or warm water. This affected residents, including a male resident with paraplegia and pressure ulcers, another male resident with paraplegia and a colostomy, and a female resident with schizophrenia and diabetes, who were unable to access hot water for personal hygiene. Interviews with residents revealed dissatisfaction and discomfort due to the lack of hot water. One resident reported not receiving showers on scheduled days and experiencing skin issues due to inadequate washing. Another resident had not been bathed for over a month and was unaware of the hot water issue. The facility's grievance form indicated that the issue had been ongoing for over a year, with a family member lodging a complaint earlier in the month. Despite obtaining bids for a new water heater, the facility had not resolved the issue, leaving the resolution section of the grievance form blank. Staff interviews indicated a lack of awareness and communication regarding the hot water issue. The Administrator and Maintenance Director were aware of the problem but were waiting for corporate approval to proceed with repairs. The Maintenance Director expressed frustration over the delay, while the Assistant Director of Nursing and a CNA were unaware of the extent of the issue. The charge nurse acknowledged the potential negative outcomes of not having hot water, such as ineffective handwashing and medication administration. The facility did not have a policy or protocol for addressing the lack of hot water in resident rooms.
Failure to Timely Change Midline Catheter Dressing
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a Midline catheter. The dressing on the resident's Midline catheter, which was used to deliver intravenous medications, was not changed for 15 days, despite professional standards requiring dressing changes every 5-7 days. Additionally, there were no orders documented for the dressing changes to be performed on the Midline catheter site, which could lead to an increased risk of infection and cross-contamination. The resident involved was in a persistent vegetative state and dependent on staff for all activities of daily living. The resident's medical history included hypertension, diabetes, aphasia, and stroke. Observations revealed that the dressing on the Midline catheter was dated 12/16/24 and had not been changed by 12/31/24. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), indicated a lack of awareness and oversight regarding the dressing change schedule. The facility's policy required dressing changes at least every 5-7 days, but this was not adhered to, leading to the deficiency.
Failure to Administer Prescribed Ketoconazole Shampoo
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the availability and application of Ketoconazole External Shampoo as ordered by the physician. The resident, who was in a persistent vegetative state and dependent on staff for all activities of daily living, had a care plan that included the application of the shampoo to treat a rash. However, the shampoo was not available or applied as ordered between the specified dates. The deficiency was identified through record reviews and interviews. The resident's administration record indicated that the shampoo was pending arrival from the pharmacy on one occasion and noted as 'other/see Nurses Notes' on another. Interviews with staff revealed a lack of communication and awareness regarding the order for the special shampoo. The Director of Nursing (DON) and other nursing staff were unsure if the shampoo had been used, and there was no documentation confirming its application. The facility's policy required accurate and timely pharmacy services, but the failure to ensure the availability and use of the prescribed shampoo placed the resident at risk of not receiving necessary treatment. The DON acknowledged the risk of an ongoing condition due to the lack of treatment, although no rash or condition was observed during a check of the resident. The report highlights a breakdown in communication and documentation among the nursing staff regarding the administration of the prescribed treatment.
Failure to Identify and Treat Resident Wounds
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two residents. Resident #56, a male with heart failure and diabetes, was at risk of developing wounds and pressure ulcers. Despite having multiple open ulcers on his right lower leg, the facility staff, including the LVN and ADON/WNC, were unaware of the wounds, and the resident was not receiving treatment. The resident expressed frustration that the staff did not know about his wounds, which had been present for one and a half to two months. Resident #24, a male with a history of stroke, peripheral vascular disease, and diabetes, also experienced a deficiency in care. His care plan was updated only after surveyor intervention to reflect an autoimmune disease-induced wound on his left leg. Despite weekly skin assessments, the LVN responsible for his care was unaware of the wound until it was observed by the surveyor. The resident communicated that the wound was irritating, and the LVN acknowledged that the wound was not present during the previous assessment. The facility's failure to identify and provide necessary care for the wounds of Residents #24 and #56 could prevent the residents from receiving timely treatment and lead to worsening conditions. The DON, who was new to the facility, was unaware of the wounds and initiated a skin sweep to identify other residents with untreated wounds. The facility's policy on changes in residents' conditions was not effectively implemented, leading to a lack of communication and documentation regarding the residents' skin impairments.
Removal Plan
- Resident #24 and #56 had a skin assessments performed by the nurse and referred to wound care management for new treatment orders and Plan of Care updated.
- The Medical Director was notified of the IJ.
- The DON/designee initiated in-services with nursing staff and CNA's on how to identify and manage changes in condition and how to communicate the changes to nurse management via SBAR and complete skin assessments in PCC.
- Any staff not currently present will be educated prior to working the floor.
- Current residents who admitted have been assessed for skin issues.
- Any issues identified by the nurse were documented in the care plan and interventions carried out by the nurse after being communicated to the wound care physician.
- The DON/designee will audit 5 random resident skin assessments visually, return demonstration, each week.
- The DON will monitor progress in the wound care audit log.
Improper Food Storage in Facility Kitchen
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 facility's kitchen, several deficiencies were noted. In the refrigerator, there were seven tomatoes and four carrots with fuzzy white and black spots, indicating spoilage. Additionally, a bag of bacon and a bag of ham were found open and exposed to air. In the freezer, a box of striped pangasius fillet and a box of beef patties were also found open and exposed to air. On the seasoning shelf, multiple containers of spices, including paprika, poultry seasoning, ground nutmeg, chili powder, ground cinnamon, garden seasoning, and ground black pepper, were found open and exposed to air. The Dietary Supervisor, during an interview, stated that he conducted daily walk-throughs of the kitchen and checked food storage throughout. He mentioned that the entire dietary department was responsible for ensuring proper food storage. Despite these measures, the improper storage of food items was observed, which could place residents at risk for food-borne illness. A request for the facility's food storage policy was made to the Administrator, but it was not provided before the survey exit.
Failure to Deliver Saturday Mail to Residents
Penalty
Summary
The facility failed to ensure that residents received their mail delivered on Saturdays in a timely manner, which could affect 80 residents by placing them at risk of not receiving mail promptly. This deficiency was identified through interviews and record reviews, revealing that mail delivered on Saturdays was not distributed to residents on the same day. Instead, the mail was placed in a locked office, and residents would not receive it until Monday unless a director was present to deliver it or the Activities Director was called in for urgent deliveries. Resident #45, a [AGE] year-old with diagnoses including anemia, hypertension, seizure disorder, anxiety disorder, and schizophrenia, reported not receiving several mailed items. The resident had a BIMS score of 15, indicating intact or borderline cognition, and was on anti-anxiety medications. Interviews with various staff members, including the BOM, DON, ADON, and the Activities Director, revealed a lack of clarity and consistency in the facility's mail delivery process on Saturdays. The facility's policy, dated December 2006, stated that mail should be delivered to residents within 24 hours of delivery, including Saturdays, but this was not adhered to.
Failure to Provide Grievance Information to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with information on how to file grievances, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This deficiency was observed in two residents, both of whom had intact or borderline cognition. One resident reported that staff withheld grievance forms to prevent her from filling them out, while another resident stated that she was discharged after repeatedly calling the state to complain. Observations revealed that grievance forms were not readily available, and there were no postings related to the facility's grievance policy. Interviews with staff members provided inconsistent information about the availability and location of grievance forms. Some staff indicated that forms were available at the nurse's stations or reception desk, while others mentioned the use of a QR code to access forms. The Administrator admitted to temporarily removing grievance forms from the hallway to prevent one resident from continuously filling them out. Despite requests, the facility's grievance policy was not provided before the survey exit.
Failure to Provide Trapeze Bar for Resident Repositioning
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not providing a trapeze bar for repositioning in bed. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a medical history that included paraplegia, among other conditions. Despite having a physician's order from a previous facility for a trapeze bar to assist with bed mobility, the resident did not receive one upon admission to the current facility. This lack of accommodation required the resident to use the call light to request staff assistance for repositioning, as he was unable to do so independently without the trapeze bar. Interviews with facility staff, including the Regional Team Rehab Director and the Physician, revealed a lack of awareness regarding the resident's need for a trapeze bar. The Physician confirmed that the order for the trapeze bar should have transferred with the resident's other medical orders. However, the facility did not provide a relevant policy when requested, indicating a possible gap in the process of accommodating resident needs. The Physician also noted that the resident was not bedbound and could transfer himself, suggesting that staff assistance was deemed sufficient, although this did not align with the resident's expressed needs and previous accommodations.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, leading to deficiencies in housekeeping and maintenance services. Resident #56, a male with multiple diagnoses including anemia, heart failure, and diabetes, was found to have peeling wallpaper in his room, which had been in disrepair since his admission in August 2024. The Maintenance Supervisor was unaware of the issue, as it had not been reported or logged in the grievance records. The resident expressed dissatisfaction with the room's appearance, which did not provide a homelike environment. Resident #135, a male with paraplegia, dementia, and a Stage 2 pressure sore, experienced inadequate cleaning services in his room. Upon observation, dried white spots and a tubing cap were found on the floor near his bed and IV pole, despite the presence of a wet floor sign. The resident, who had been admitted recently, noted the room's unclean state and questioned the effectiveness of the cleaning. The Housekeeping/Maintenance Director acknowledged a shortage of staff on the day in question, which may have led to missed cleaning duties. Interviews with staff revealed that housekeeping services were expected to be performed daily, including sweeping and mopping. However, due to staff shortages and the facility inspection, some rooms may not have been cleaned as required. The Housekeeping/Maintenance Director and other staff members recognized the potential risks of unsanitary conditions, including infection and decreased resident satisfaction. Despite these acknowledgments, the facility's policy on maintaining a homelike environment was not fully implemented, as evidenced by the deficiencies observed.
Failure to Secure Smoking Materials and Hazardous Items
Penalty
Summary
The facility failed to ensure that Resident #65's smoking materials were kept at the nurses' station as per the facility's smoking policy. Resident #65, a male with chronic obstructive pulmonary disease, diabetes mellitus, malnutrition, and anxiety disorder, was observed with a pack of cigars and a lighter in the courtyard. The resident admitted to keeping these items in his room, contrary to the policy that required such materials to be stored at the nurses' station. The facility's administrator was unaware of this non-compliance and believed smoking materials were stored in a locked medication room. Additionally, the facility did not secure hazardous items such as razors and hand sanitizer in the secured unit, which was easily accessible to residents. Observations revealed a gallon jug of hand sanitizer and disposable razors stored in an unlocked area. Staff members, including a CNA and the DON, were unaware of the presence of these items in the unsecured room. The DON acknowledged that these items should have been stored in a locked area to prevent resident access. The facility's policy on medication storage required that antiseptics, disinfectants, and germicides be stored separately from regular medications and in a secure manner. However, no specific policy related to the storage of hazardous items was provided by the facility at the time of the survey exit. The unsecured storage of these items posed a risk of poisoning or injury to residents in the secured unit.
Failure to Maintain Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, impacting their quality of life. One resident, a male with a history of hip fracture and Stage III pressure ulcer, was not assisted to get out of bed for four months despite expressing a desire to do so. The resident required maximum assistance for transfers and had a moderately impaired cognitive status. Staff did not use a Hoyer lift to assist him, and he remained in bed, which could lead to depression. It was only after the issue was raised that the resident was finally assisted out of bed using a Hoyer lift and placed in a geri-chair. Another resident, a male with multiple diagnoses including anemia and heart failure, was observed wearing a hospital gown that exposed his back due to a lack of personal clothing. The resident reported that most of his clothes were left at a previous facility, which had closed, and he had informed the Administrator multiple times without resolution. The Administrator acknowledged the issue but had not yet recovered the clothing or replaced it, citing difficulty in finding the resident's size. This situation affected the resident's self-esteem and dignity.
Failure to Assist Resident with Transfers
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically in getting out of bed. The resident, a male with a history of hip fracture and a Stage III pressure ulcer, required maximum assistance for transfers and had been confined to bed for four months. Despite expressing a desire to get out of bed, the staff did not assist him, citing his weakness and a previous fall as reasons. The resident's care plan did not include assistance for getting out of bed, and staff did not utilize a Hoyer lift or provide a wheelchair or geri-chair for transfers. Interviews with staff revealed a lack of awareness and action regarding the resident's needs. The Assistant Director of Nursing (ADON) acknowledged the resident's inability to assist in transfers and the need for a Hoyer lift, while the Director of Nursing (DON) was unaware that the resident had not been getting out of bed. It was only after staff began searching for a wheelchair or geri-chair that the resident was finally assisted out of bed using a Hoyer lift. The facility's policy on resident rights emphasized the importance of treating residents with respect, kindness, and dignity, which was not upheld in this case.
Inadequate Staffing Leads to Resident Elopement
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure the safety and well-being of its residents, particularly in the case of a resident with moderately impaired cognition and wandering behaviors. This resident, who was dependent on staff for various activities of daily living and had a history of wandering, managed to leave the secured unit and enter the main area of the facility. At the time of the incident, both the assigned Charge Nurse and CNA were off the unit, leaving the resident unsupervised and able to exit the secured area. Observations and interviews revealed that the staffing levels were inadequate to meet the needs of the residents in the secured unit. The Charge Nurse was responsible for both the secured unit and another hall, which often left the secured unit without sufficient supervision. Staff members reported difficulties in hearing alarms and monitoring residents due to their responsibilities in other areas, contributing to the resident's ability to leave the secured unit unnoticed. The facility's staffing policy indicated that adequate staffing should be maintained to meet the needs of the residents, but the current staffing levels were insufficient to prevent incidents like the one involving the resident. The Director of Nursing and other staff acknowledged the challenges posed by the current staffing levels, particularly when residents required two staff members for care or when altercations occurred. Despite the administrator's belief that the risk to residents was low due to locked facility exit doors, the incident demonstrated a clear deficiency in staffing and supervision.
Duplicate Bupropion Therapy Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medication, specifically duplicate therapy with Bupropion, an anti-depressant. The resident, a female with intact cognition and diagnoses of anxiety disorder and depression, was prescribed Wellbutrin XL (Bupropion HCL) 150 mg every evening starting in July 2024. In October 2024, a new order for Bupropion HCl ER 150 mg every 24 hours was added, resulting in the resident receiving both medications concurrently. This duplication occurred because a Licensed Vocational Nurse (LVN) mistakenly thought she had discontinued the earlier order when the new one was received. The error was identified through observation, interviews, and record reviews. The resident did not report any issues with her medications and was not observed to have negative outcomes. However, the Director of Nursing (DON) acknowledged the risk associated with the duplicate medication, noting that Bupropion carries a black box warning for potential behavioral changes and increased risk of suicidal thoughts. The facility lacked a specific policy for unnecessary medications, relying instead on a CMS tool for guidance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5 percent, resulting in a 15 percent error rate. This was observed in three residents who did not receive their prescribed medications as required. LVN A did not administer Famotidine to a resident via J-tube because the medication was not available, despite it being marked as delivered in the system. The resident had a history of GERD and required the medication to manage his condition. LVN A had notified the pharmacy, but the medication was still pending approval from the insurance. MA B was responsible for administering medications to two residents but failed to do so correctly. One resident did not receive Baclofen and Pregabalin, and was given the wrong dose of Colace. The Baclofen was not administered because it did not appear on the computerized MAR, and the Pregabalin was pending arrival from the pharmacy. The Colace administered was not the correct type as per the order. Another resident did not receive her Flonase nasal spray because it was not available in the medication cart, although it was later found in another nurse's cart. Interviews with the staff revealed communication and procedural lapses. MA B did not inform LVN A about the missing Baclofen, and there was confusion about the availability of medications due to delivery issues. The DON, who was new to the facility, was unaware of these issues and had advised nurses to place orders as STAT if a dose was due the same day. The facility's policy emphasized preventing medication errors, but the staff failed to adhere to these guidelines, leading to the deficiencies observed.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in deficiencies in the care of three residents. Resident #54, a male with a hip fracture, Stage III pressure ulcer, and a Foley catheter, was not placed on enhanced barrier precautions. Observations revealed that there was no signage or personal protective equipment (PPE) outside his room, and staff were unaware of the need for enhanced barrier precautions. LVN A, who provided care to Resident #54, did not use a gown and was unfamiliar with enhanced barrier precautions, indicating a lack of training and awareness among staff. Resident #33, a male with severe cognitive impairment, stroke, diabetes, quadriplegia, and multiple medical devices, was also not placed on enhanced barrier precautions. His room lacked the necessary signage and PPE, and both CNA E and LVN F, who were assigned to his care, were unaware of what enhanced barrier precautions entailed. The Assistant Director of Nursing (ADON) mentioned that an in-service on enhanced barrier precautions had been conducted, but the staff's lack of knowledge suggested that the training was ineffective or not properly implemented. Resident #24, a male with severe cognitive impairment, stroke, and diabetes, experienced a lapse in infection control during incontinence care. LVN G failed to change gloves and perform hand hygiene after cleaning the resident, which posed a risk of infection. The ADON, who was not the designated Infection Preventionist, and the Director of Nursing (DON) acknowledged the risk of infection due to these lapses in protocol. The facility's infection control policies, as reviewed, were intended to prevent and manage infections, but the observed deficiencies indicated a failure in their implementation.
Failure to Provide Catheter Stabilization Device
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who was incontinent of bladder, specifically in the area of catheter care. The resident, a male with a moderately impaired cognitive status, had a foley catheter but lacked a catheter stabilization device. This deficiency was identified during an observation and interview where the resident and a Licensed Vocational Nurse (LVN) provided conflicting accounts regarding the presence of the stabilization device. The LVN initially stated that the resident removed the device, but the resident denied ever having one. The absence of this device was confirmed by the Director of Nursing (DON), who acknowledged that residents with foley catheters should have orders for such devices to prevent dislodgement. The resident's medical history included a hip fracture and a Stage III pressure ulcer, and he was diagnosed with obstructive and reflux uropathy. The facility's policy on urinary continence and incontinence, revised in December 2010, required the provision of appropriate services and treatment to help restore or improve bladder function and prevent urinary tract infections. However, the resident's care plan did not include an order for a catheter stabilization device, which could place him at risk for urinary tract infections and urethral damage. This oversight highlights a failure in adhering to the facility's policy and ensuring the resident's safety and well-being.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who required oxygen therapy, as evidenced by outdated and improperly maintained oxygen equipment. Resident #1, a female with multiple diagnoses including metabolic encephalopathy and heart disease, was observed not using her nasal cannula due to discomfort, and her oxygen tubing and humidifier bottle were not changed as per the facility's policy. The equipment was dated from the previous month, indicating a lapse in the weekly maintenance schedule. Resident #2, a male with chronic respiratory failure and other health issues, was observed using his nasal cannula continuously, but his oxygen equipment was also outdated. The tubing was dated from September, and the humidifier bottle's date was partially visible, suggesting it had not been changed in accordance with the weekly requirement. Despite the resident's continuous need for oxygen, the facility did not adhere to the established protocol for equipment maintenance. Resident #3, a female with a history of cerebral infarction and other conditions, was found with undated oxygen tubing and no humidifier present. The resident's representative expressed concerns about the lack of ear protectors but did not notice the equipment's outdated status. Interviews with the facility's LVN and the newly appointed DON revealed a lack of awareness and adherence to the policy requiring weekly changes of oxygen equipment, which could increase the risk of infection among residents.
Lack of Activities for Residents in Secure Unit
Penalty
Summary
The facility failed to provide individualized and group activities for four residents on the secure unit, as required by their comprehensive assessments and care plans. These residents, all with severe cognitive impairments and various mental health diagnoses, were not engaged in activities that could support their physical, mental, and psychosocial well-being. Observations revealed that there were no structured activities in place, and the residents were often left to wander or sit idly without interaction or engagement. The care plans for these residents indicated a need for specific activities, such as music therapy, fitness, and socialization, to prevent social isolation and manage behaviors. However, there was no documented evidence of activities assessments or progress notes in their clinical charts. Interviews with staff revealed that the activity director was stretched thin and unable to provide adequate activities for the secure unit, and the CNAs were not trained or equipped to fill this gap effectively. The facility was also experiencing staffing challenges, with the recent departure of key personnel, including the DON and a CNA who had been assisting with activities. The lack of a dedicated activity director for the secure unit and insufficient staffing contributed to the deficiency. Observations showed that residents were not provided with activity calendars, and there was a lack of engagement from staff, leading to increased risks of resident altercations and falls.
Inadequate Supervision Leads to Resident Elopement and Intoxication
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents known for seeking alcohol and becoming intoxicated. Resident #1, with a history of Parkinson's disease, bipolar disorder, and schizophrenia, was moderately cognitively impaired and had a known history of purposeful wandering. Despite being placed in a secure unit for safety, Resident #1 frequently left the facility without signing out, often returning intoxicated and displaying aggressive behavior. The facility's interventions, such as monitoring for tailgating and placing the resident in a secured locked unit, were insufficient to prevent the resident from leaving unsafely. Resident #16, a new admission with no documented diagnoses, was also known for seeking alcohol and leaving the facility without signing out. On one occasion, Resident #16 left through the back gate during a staff shift change and was later found intoxicated by the police. The facility's care plan for Resident #16 included supervision with smoking and following facility guidelines for unsafe practices, but these measures were not effectively implemented, as evidenced by the resident's unsupervised departure and subsequent intoxication. The facility's policy on accidents and hazards emphasized the need for adequate supervision and assistive devices to prevent accidents, including identifying and evaluating hazards, implementing interventions, and monitoring their effectiveness. However, the facility failed to adhere to these guidelines, resulting in residents leaving the facility unsupervised and at risk of harm. Interviews with staff revealed inconsistencies in the supervision and monitoring of residents, contributing to the identified deficiencies.
Removal Plan
- Residents who leave the facility on pass were assessed and noted to be oriented to person and place.
- A review of the resident pass policy conducted by the administrator determined that while there is no specific guidance requiring a resident to state where they are going or how long they will be out, we will amend our leave of absence form to include these as optional fields.
- The nursing staff will monitor the resident's whereabouts from the hours of 10:00 PM-6:00 AM, this will be done every hour and will populate in our EMR software as an action item to be completed.
- The administrator and DON will educate the residents on the proper procedure for going out on pass including entering and exiting only through the front door, signing in and out, and letting staff know when they return.
- Alarms for the doors were purchased by maintenance and will be placed in doors that lead out of other locations.
- The gate at the back smoking area has been secured and can no longer be pulled open, unless at the actual gate opening and closure which are used in the event of an emergency.
- The administrator and director of nursing were educated on proper out on pass procedure including supervision, by the regional nurse manager.
- Training of facility staff on resident pass procedures and keeping residents free of accidents and hazards was initiated by the Administrator and DON.
- The Administrator has created an education for the residents regarding leaving the facility that includes a signed acknowledgement form.
- The administrator, DON, or designee will ensure the new sign out sheet is correctly adhered to daily for two weeks, weekly for two weeks and monthly for two months.
- Any negative findings will be taken to the administrator for immediate correction.
- Administrator or DON will continue to audit the passbook daily in the morning standup meeting as an ongoing process.
- The results of the new audit process will be reported to the QAPI team.
- The Medical Director was notified of the deficiency.
- All findings will be reported to the QAPI team monthly for quality assurance.
- Facility will have completed education, if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided.
Deficiency in Call Light System Leads to Delayed Resident Assistance
Penalty
Summary
The facility was found to have a significant deficiency in its communication system, specifically the call light system, which was not functional in several halls, including halls 100, 300, 400, and 500. This deficiency was identified through observations, interviews, and record reviews. On multiple occasions, it was noted that call lights in resident rooms and bathrooms were not working, leaving residents without a means to call for assistance. This lack of a functional call system was observed to cause delays in assistance, with residents reporting feelings of abandonment and fear due to the inability to reach staff when needed. Several residents were directly affected by this deficiency. For instance, a resident with paraplegia and PTSD reported feeling abandoned as no staff checked on her overnight, and her call light was non-functional. Another resident, who required assistance with a G-Tube, experienced delays of over an hour at night to receive help. Additional residents reported waiting for extended periods, sometimes over two hours, for assistance with essential needs such as repositioning, changing, and managing medical equipment like a CPAP machine. These delays were attributed to the non-functional call light system, which was not audible at the nursing stations, and the lack of visibility of rooms from these stations. The facility's grievance logs and interviews with residents further highlighted the impact of the non-functional call light system. One resident had previously filed a grievance about unanswered call lights and facility phones, with no resolution noted. Observations confirmed that call lights were not sounding at nursing stations, and in some cases, lights above resident rooms were not illuminating, exacerbating the issue. This situation led to the identification of an Immediate Jeopardy, indicating a severe risk to resident safety and well-being due to the facility's failure to provide a reliable means for residents to communicate their needs to staff.
Removal Plan
- Conduct in-service training for all staff on the importance of resident checks and proper use of the call light system.
- Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights.
- Conduct checks of call light systems to ensure ongoing functionality.
- Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being.
- Conduct audits for compliance with the above actions.
- Any noncompliance or issues identified during audits must be reported to the DON and Administrator for corrective action.
- Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families.
Failure to Provide Adequate Care and Address Call Light Issues
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as Resident #15, according to professional standards of practice and the resident's comprehensive person-centered care plan. On the overnight shift, Resident #15 did not receive the necessary care, resulting in her right leg hanging from the bed throughout the night, causing it to become swollen. The resident was in visible distress, experiencing discomfort and pain, and was observed crying out for help for an extended period without receiving assistance. The call light and bathroom call light in her room were not functioning, which contributed to the delay in receiving care. Resident #15, a cognitively intact individual with paraplegia and other medical conditions, was moved to a different hallway where she was the only resident. This move was reportedly due to her request for a single room as she transitioned to long-term care. However, the staff responsible for her care were not adequately informed of her presence on the new hallway, leading to a lack of regular checks and assistance. Interviews with staff revealed that some were unaware of her relocation, and others acknowledged the ongoing issues with the call light system, which had not been promptly addressed. The facility's failure to ensure the functionality of the call light system and to conduct regular checks on Resident #15 placed her at risk of harm. Despite the resident's repeated requests for help and the known issues with the call light system, the facility did not take immediate action to rectify the situation, resulting in the resident experiencing significant distress and discomfort. The deficiency was identified as an Immediate Jeopardy situation, indicating a serious breach in the standard of care expected in the facility.
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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