Crestway Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 7181 Crestway Dr, San Antonio, Texas 78239
- CMS Provider Number
- 675171
- Inspections on file
- 51
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Crestway Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment died in the facility, and staff did not notify the family of the death as required by policy, following instructions from law enforcement who were investigating the incident as a potential crime scene. The family was only informed after they contacted the facility, at which point they were referred to the police for further information.
Multiple residents with severe cognitive and physical impairments had their use of side rails as restraints unreported in the MDS, despite staff and DON confirming restraint use. Additionally, a resident receiving hospice care and another with a surgical wound were inaccurately documented in their MDS assessments, with the DON attributing errors to the absence of an MDS nurse. These documentation failures were identified through record review, staff interviews, and observation.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables or specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risks, reviewing risks and benefits with the resident or representative, obtaining informed consent, or ensuring proper installation and maintenance.
Several residents were prescribed psychotropic and psychoactive medications without appropriate diagnoses or monitoring. One resident received an antipsychotic for agitation without documented behavioral issues, another was given antidepressant and antianxiety medications without monitoring for side effects or behaviors, and a third was administered multiple psychoactive drugs without supporting diagnoses. Facility policies requiring clinical indications and monitoring for such medications were not followed.
Surveyors found that the kitchen dry storage area had two containers of sugar with unsecured lids, a box of juice cups with spillage and gnats, and two boxes of funnel cake mix lacking manufacturer expiration dates. The Dietary Manager and Registered Dietitian confirmed the importance of proper food storage and handling, and facility policy requires safe food handling practices.
Staff failed to follow infection control protocols by not performing hand hygiene between glove changes and after touching potentially contaminated surfaces during care for two residents, including colostomy and tracheostomy procedures. The DON confirmed these actions were not in line with facility policy and could lead to infection transmission.
A resident with newly diagnosed Major Depressive Disorder and Schizophrenia was not referred for a PASARR Level II evaluation, despite severe cognitive impairment and ongoing psychiatric care. The responsibility for PASARR referrals was unassigned due to a vacant MDS Coordinator position, and the facility could not provide a PASARR policy when requested.
A resident with multiple medical conditions was assessed as a safe, independent smoker, but the care plan was not updated to reflect this change, continuing to require storage of cigarettes and lighters in the med room. The DON confirmed the care plan should have been revised after the assessment, but this was not done due to the absence of the MDS nurse responsible for care plan updates.
A resident with impaired mobility and a history of Critical Illness Myopathy experienced prolonged foot pain and developed long, ingrown toenails after an LVN failed to assess his feet during weekly skin checks. The DON later discovered the resident's toenails were significantly overgrown and ingrown, despite facility policy requiring thorough skin and foot assessments.
A CNA failed to clean the suprapubic area of a resident with an indwelling urinary catheter and multiple medical conditions during incontinence care, despite facility policy and recent peri-care training. The omission was acknowledged by the CNA and confirmed by the DON, highlighting a lapse in required perineal care procedures.
A nurse flushed a resident's gastrostomy tube by pushing water with a syringe plunger instead of using gravity, contrary to the resident's care plan and physician orders. The resident, who had severe cognitive impairment and was dependent on enteral nutrition, was at risk for complications due to this improper technique. Both the nurse and DON acknowledged that gravity should have been used, and the facility lacked a specific policy on this procedure.
Expired bottles of Gentle Lax and Acetaminophen 500mg were found on a medication cart, with both an LVN and the DON confirming that these should not be administered due to potential ineffectiveness or adverse reactions. Facility policy requires expired medications to be returned or destroyed, but these were not removed as required.
A resident's medical record was not updated to include a new diagnosis of general anxiety after a psychiatric physician prescribed diazepam for this condition. Although the medication was ordered and administered, the diagnosis was missing from the electronic medical record and face sheet. The DON confirmed the oversight, noting the absence of an MDS nurse contributed to the incomplete documentation.
A deficiency was found when an oxygen cylinder was improperly stored in a resident's room, in violation of facility policy requiring such cylinders to be kept in a designated storage area. The resident had multiple medical conditions and required assistance with transfers. Staff interviews confirmed the cylinder should not have been in the room, and facility policy prohibits this practice.
A medication cart was left unlocked and unattended in a hallway, with its computer screen displaying a resident's personal and medical information. An LVN admitted to forgetting to lock the screen, resulting in exposed confidential data. The DON confirmed that staff are expected to lock computer screens to protect resident information, in accordance with facility policy.
A resident with cognitive impairment and swallowing difficulties had a physician-ordered change from a pureed to a mechanical soft diet, but the care plan was not updated to reflect this change. Although the correct diet was provided, staff interviews revealed confusion about who was responsible for updating the care plan, resulting in the care plan not matching the resident's current dietary needs.
A resident with multiple complex medical conditions, including an indwelling urinary catheter and a stage 4 pressure ulcer, did not have these needs reflected in their comprehensive care plan. Although medical orders and assessments documented the catheter and wound care requirements, the care plan was not updated by the interdisciplinary team to include these interventions, as confirmed by staff interviews and record review.
A resident with severe cognitive impairment and multiple medical conditions requiring enteral feeding did not receive the prescribed amount of water flushes before and after medication administration. An LVN administered only 10 ml and 15 ml water flushes instead of the ordered 30 ml, contrary to physician's orders and facility policy, resulting in a deficiency in care.
Medication carts on two separate halls were repeatedly left unlocked and unattended, with both an LVN and a respiratory technician admitting to forgetting to secure the carts. Staff interviews and facility policy confirmed that carts are required to be locked when not in use to prevent unauthorized access, especially due to residents who wander.
A resident with cognitive impairment, hemiplegia, and a mechanically altered diet was not provided with an ordered Adult Sip Cup at the start of a meal, resulting in repeated beverage spillage. Staff interviews and documentation confirmed the resident required adaptive equipment and assistance, but the appropriate device was only provided after the resident experienced difficulty.
Two residents with significant mobility impairments were injured due to improper transfer procedures: one was transferred without a mechanical lift despite being dependent on it, resulting in a femoral fracture, while another was dropped when a CNA performed a single-person mechanical lift transfer, causing a facial laceration. In both cases, staff did not follow established protocols requiring mechanical lifts and two-person assistance.
A resident with significant respiratory and mobility needs reported being sprayed with an unknown substance by an unidentified staff member. The facility failed to fully investigate the grievance, did not identify or interview all involved staff, and did not provide the required follow-up or communication to the resident or her family, as mandated by facility policy.
A resident with significant mobility impairments and a history of mechanical lift transfers did not have this requirement reflected in her care plan, despite documentation and staff knowledge of her needs. On one occasion, staff transferred her without a mechanical lift due to equipment unavailability, and the care plan remained outdated, relying instead on CNA tracking lists.
CNAs failed to wear required gowns while transferring a resident on enhanced barrier precautions (EBP) for a tracheostomy and ventilator dependence, using only gloves despite facility policy and signage. The staff were unaware of the resident's EBP status and believed the precautions were for the roommate, even though the resident required total assistance and had significant medical needs. The DON confirmed that gowns and gloves were required for such transfers according to facility policy.
A Respiratory Therapy Director worked as a Respiratory Therapist without holding a valid Texas state license for an extended period, with only national certification and a future-dated state license present in the personnel file. The HR department relied solely on national licensure, and a remedial plan from the state board confirmed the individual practiced without proper state credentials, contrary to facility policy.
A resident with significant disabilities was subjected to rough handling by a CNA, resulting in bruising and emotional distress. Despite being cognitively intact and social, the resident was dependent on staff for care. Video evidence showed the CNA's abusive actions, which were inconsistent with the resident's care plan and facility's abuse prevention policy.
A resident in an LTC facility did not receive prescribed doses of Lamictal and Phenobarbital, and Ativan was improperly administered for agitation instead of seizures. The facility's staff failed to document the omissions and did not follow procedures for verifying unclear orders or addressing medication unavailability, leading to deficiencies in pharmaceutical services.
A facility failed to ensure privacy for two residents during personal care, leading to a deficiency. One resident, who requires assistance due to cerebral cysts, was exposed during incontinence care as the privacy curtain was not fully closed, and the camera in the room was not obstructed. The other resident, with mild cognitive impairment, was captured on camera without consent. The facility did not adhere to privacy protocols, resulting in a breach of privacy and dignity.
A resident with a history of stroke and physical debility did not receive necessary therapy services due to insurance approval issues, despite having an active order for evaluation and treatment. The facility failed to implement a comprehensive care plan, leading to dissatisfaction from the resident and their responsible party. The lack of therapy services and unclear processes for handling therapy referrals contributed to the deficiency.
A resident with a history of stroke and physical debility did not receive required PT, OT, and ST services due to insurance issues, despite having physician orders. The facility's process for therapy orders involved insurance review first, and therapy screening depended on the resident's insurance type. The lack of documentation and clear policy for therapy referrals contributed to the deficiency.
A resident with complex medical needs was mistakenly given another resident's medications, including atorvastatin, labetalol, and hydralazine, by an LPN during an evening medication pass. The error was realized partway through the administration, and the resident was monitored for adverse reactions, with none observed. The facility's medication administration policies were not followed, as the LPN failed to verify the resident's identity and medication labels properly.
A resident on Enhanced Barrier Precautions did not receive proper infection control measures during care. LVN A and CNA B failed to wear gowns, and LVN A did not change gloves or perform hand hygiene while providing wound care. The resident had multiple indwelling devices and required EBP, but staff were unaware or did not adhere to protocols, leading to potential cross-contamination risks.
The facility failed to ensure resident privacy during personal care for four residents, as staff did not adequately close privacy curtains, doors, or blinds. This deficiency was observed during incontinence care for residents with various medical conditions, including cognitive impairments. Staff interviews confirmed the importance of maintaining privacy to prevent residents from feeling embarrassed or ashamed, as outlined in the facility's policies on resident rights and dignity.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended. The Respiratory Treatment Cart #1 and Wound Treatment Cart #2 were both found unlocked, with the latter containing treatments that could be ingested by residents, posing a risk of adverse reactions. The DON confirmed the expectation for carts to be locked when not in use.
The facility failed to maintain proper infection control practices during perineal and incontinent care for several residents. Staff did not change gloves or perform hand hygiene at critical points, such as after removing soiled briefs or before handling clean items. Observations revealed systemic failures in adhering to infection control guidelines, affecting residents with various medical conditions.
A facility failed to develop a comprehensive person-centered care plan for a resident, neglecting critical areas such as cognitive loss, urinary incontinence, and nutritional status. The resident had multiple diagnoses, including diabetes and hypertension, and was dependent on assistance for daily activities. Despite these needs, the care plan only addressed a fall incident, and staff interviews revealed that the care plan was not completed in a timely manner following the MDS assessment.
The facility failed to maintain sanitary conditions for two residents requiring tracheostomy care. Aerosol tubing for both residents was found on the floor and reconnected without being replaced, as the LVN was not informed of the contamination. This oversight was acknowledged by the CNA involved, and the DON emphasized the importance of reporting such incidents to prevent infection.
A facility failed to document the insertion and care of a suprapubic catheter for a resident, leading to incomplete medical records. An LVN changed the catheter but did not record the procedure or urine output, despite the resident's report and the LVN's acknowledgment. The DON confirmed that such events should be documented, but due to a busy night, the LVN neglected this duty, potentially affecting the resident's continuity of care.
A resident's catheter bag was found on the floor instead of being anchored to the bed rail, posing an infection control issue. The resident, with a history of diabetes and UTIs, reported that morning staff did not empty the bag, although other shifts did. Staff interviews confirmed the improper placement, and the facility's policy required catheter bags to be kept off the floor.
The facility did not comply with professional standards for food storage, as observed in the kitchen where two open gallon jugs of ranch dressing were found unlabeled in the reach-in refrigerator. The Dietary Manager confirmed that all food should be labeled with the date opened and use-by date, as per the facility's policy. This oversight placed residents at risk for foodborne illness.
The facility failed to accurately document blood pressure readings for residents on hypertension medication, leading to repeated entries in the EMAR. Nursing staff admitted to using a system feature that duplicated previous readings, which did not reflect the true effectiveness of the medication. This affected residents with varying cognitive abilities, potentially impacting their care.
A resident with a history of cerebral infarction, tracheostomy status, anxiety disorder, and schizophrenia had a care plan that failed to include necessary interventions for mitten restraints. The care plan only required visual checks every two hours, despite physician orders to remove the restraints for skin checks and exercises. Nursing staff followed the physician's orders, but the care plan documentation was incorrect.
The facility failed to provide adequate supervision and security for residents at risk of elopement, leading to an incident where a resident with dementia left the facility unsupervised and was found miles away. The front door was left unlocked and unmonitored during specific hours, and staff were unaware of which residents required supervision. This lack of oversight and security measures resulted in an Immediate Jeopardy situation.
A facility failed to maintain accurate medical records for a resident, specifically regarding meal consumption on two consecutive days. The resident, who required total assistance for eating, did not have documented records of meals provided on those days. Interviews revealed that the meals were given but not documented due to agency staff not being fully oriented to the facility's documentation methods.
Failure to Notify Family of Resident Death Due to Police Directive
Penalty
Summary
Facility staff failed to notify the resident's representative or family of a significant change in condition, specifically the death of a resident, as required by facility policy and regulatory standards. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including a healing cervical fracture, hypertension, and anxiety disorder, died in the facility. Documentation showed that staff performed CPR until EMS arrived, and the time of death was recorded. The incident was complicated by another resident's report of a possible altercation, leading to a police investigation. During the police investigation, facility staff, including the DON, ADON, and Administrator, were instructed by law enforcement not to notify the family of the resident's death, as the scene was considered a crime scene and the police stated it was their responsibility to notify next of kin. Staff complied with this directive and did not inform the family until the family called the facility themselves. At that point, the ADON confirmed the death but could not provide further details, instead directing the family to contact the police investigator for more information. Interviews with facility leadership confirmed that they did not inform the police of their regulatory requirement to notify the family, nor did they seek guidance from the Ombudsman, state program management, or the Medical Director regarding the conflict between law enforcement instructions and facility policy. The facility's own policy required timely notification of family or legal representatives in the event of significant changes in a resident's condition, but this was not followed due to the police directive.
Inaccurate Resident Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of multiple residents, as evidenced by discrepancies found in the Minimum Data Set (MDS) documentation and care plans. For several residents with severe cognitive impairment and significant physical limitations, the use of side rails as restraints was not properly identified in their MDS assessments, despite staff and the Director of Nursing (DON) confirming that the side rails were used for safety and restraint purposes. Observations and interviews revealed that these residents were totally dependent on staff for activities of daily living (ADLs), had contractures or wore mittens, and could not use the side rails for mobility, yet the MDS did not reflect restraint use as required. In addition, the facility failed to accurately document other critical aspects of resident care. One resident's quarterly MDS inaccurately indicated that the resident was not receiving hospice care, despite documentation and physician certification confirming hospice enrollment and a prognosis of less than six months to live. Another resident's MDS failed to identify the presence of a current surgical wound, even though care plans, physician orders, and weekly skin assessments documented ongoing wound care for a post-surgical wound. In both cases, the DON acknowledged the inaccuracies and attributed them to the absence of a dedicated MDS nurse, with responsibilities temporarily handled by a company nurse who was unavailable at the time. The facility's own policy requires that all individuals completing any portion of the MDS assessment attest to the accuracy of the information provided. However, the lack of accurate and timely updates to the MDS assessments resulted in documentation that did not reflect the residents' true conditions or care needs. This deficiency was identified through a combination of record reviews, staff interviews, and direct observations, affecting multiple residents and potentially impacting the quality of care provided.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the surveyor's observation that the care plan did not comprehensively cover the resident's needs, and there was an absence of clear, measurable objectives and interventions to guide staff in providing appropriate care.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report excerpt.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow required procedures before the use of a bed rail. Specifically, the facility did not attempt alternative approaches prior to bed rail use, did not assess the resident for safety risks, and did not review the risks and benefits of bed rail use with the resident or their representative. Additionally, informed consent was not obtained, and there was a failure to ensure the bed rail was correctly installed and maintained.
Failure to Ensure Drug Regimens Are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the lack of appropriate diagnoses and monitoring for several residents receiving psychotropic and psychoactive drugs. For one resident, Zyprexa was prescribed for agitation without a documented diagnosis of agitation or any behavioral disturbances, and the care plan did not address agitation or anxiety. The resident's medical records and interviews with the responsible party confirmed the absence of aggressive behaviors or a history of agitation, yet the medication continued to be administered without proper justification or review. Another resident was prescribed Remeron for depression and Buspirone for anxiety, but there was no evidence in the medical record of monitoring for behaviors or side effects associated with these medications. The care plan indicated a risk for side effects and called for monitoring, but this was not carried out. The DON acknowledged that the required monitoring was not performed, which was contrary to facility policy and expectations for medication management. A third resident received multiple psychoactive medications, including Olanzapine for agitation and Divalproex Sodium for mood, without documented diagnoses to support their use. The care plan referenced the use of these medications for agitation and mood, but the clinical record did not contain corresponding diagnoses. Facility policy required that antipsychotic medications only be used for specific, documented conditions, and that all medications be clinically indicated, but this was not followed in these cases.
Improper Food Storage and Handling in Kitchen Dry Storage Area
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen dry storage area. Two containers of sugar were found with unsecured lids, and a box containing nine individual juice cups had spillage and approximately four gnats present when the box was moved. Additionally, two boxes of funnel cake mix were present without manufacturer expiration dates, only a handwritten date was visible. These conditions were directly observed by surveyors during their inspection of the dry storage area. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) confirmed the importance of proper food storage and the risks associated with improper practices. The DM acknowledged the need to ensure foods are not expired and are properly stored to prevent contamination or cross-contamination. The RD emphasized that food should be kept in airtight containers to maintain integrity and prevent contamination from bugs or debris. Facility policy reviewed by surveyors stated that foods must be received and stored in compliance with safe food handling practices, and that dry foods should be handled and stored to maintain packaging integrity until use.
Failure to Follow Hand Hygiene and Glove Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. In one instance, a CNA changed gloves without sanitizing or washing hands while emptying a resident's colostomy bag, and again after cleaning the bag, only sanitizing hands after all tasks were completed. The CNA acknowledged receiving hand hygiene training and recognized the need to sanitize or wash hands between glove changes, especially after contact with body fluids. The Director of Nursing confirmed that the CNA should have sanitized or washed hands between glove changes according to facility policy. In another case, a respiratory therapist changed gloves without performing hand hygiene while providing tracheostomy care for a resident who was totally dependent on staff, had a tracheostomy, and required oxygen therapy. Additionally, an LVN donned gloves and a gown, then touched the privacy curtain and bed controls before administering medication through a PEG tube without changing gloves. The Director of Nursing stated that both the respiratory therapist and LVN failed to follow infection control policy, which could result in the transfer of bacteria and infection to residents. Facility policies reviewed emphasized the importance of hand hygiene and changing gloves when contamination occurs.
Failure to Refer Resident for PASARR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation after the resident was diagnosed with Major Depressive Disorder and undifferentiated Schizophrenia following admission. The resident's records showed no diagnosis of dementia, but did indicate severe cognitive impairment, ongoing use of psychotropic medications, and receipt of psychological and psychiatric services. Despite these factors and the new diagnoses, the resident's PASARR Level I screening from a previous date indicated no mental illness, and no subsequent referral for a Level II evaluation was made after the new diagnoses were established. Interviews and record reviews revealed that the responsibility for PASARR referrals typically fell to the MDS Coordinator, a position that was vacant at the time. The DON confirmed that the resident should have been referred for PASARR services following the new diagnoses but was not. Additionally, the facility was unable to provide a PASARR policy when requested during the survey.
Failure to Update Care Plan After Change in Smoking Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident following a change in smoking status, as identified through interviews and record review. The resident, an adult male with diagnoses including paraplegia, hypertension, and other conditions, was assessed as a safe and independent smoker according to a smoking assessment. Despite this assessment, the resident's care plan continued to state that all cigarettes and lighters must be stored in the medication room and that smoking was only permitted in designated areas under supervision. The care plan was not updated to reflect the resident's new status, which allowed him to keep his cigarettes and lighter per facility policy. The Director of Nursing confirmed that the care plan should have been updated after the smoking assessment, but this was not done due to the absence of the MDS nurse, who was responsible for care plan updates. The facility's policy allows residents with independent smoking privileges to keep smoking materials in their possession, but the resident's care plan did not reflect this change. This oversight was attributed to staffing issues, specifically the unavailability of the MDS nurse at the time.
Failure to Provide Proper Foot Care and Assessment
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) responsible for weekly skin assessments failed to assess a resident's feet, resulting in significantly long toenails and two ingrown toenails going unnoticed. The resident, who had a diagnosis of Critical Illness Myopathy and was at risk for skin breakdown due to impaired mobility, reported foot pain related to ingrown toenails and stated he had informed nursing staff about the issue since admission. Despite weekly skin assessments being part of the care plan, the LVN did not recall assessing the resident's feet, and the charge nurse was unaware of any foot problems. Upon assessment by the Director of Nursing (DON), the resident was found to have scaly, dry feet, all toenails were long, and both great toenails appeared ingrown, with one toenail extending approximately one inch past the nail bed and showing red spots. The DON confirmed that the treatment nurse should have identified these issues during routine assessments, and that certified nursing assistants (CNAs) should also report any skin problems. Facility policy required comprehensive physical exams, including skin and foot assessments, but these were not properly completed for this resident.
Failure to Provide Complete Incontinence and Catheter Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide appropriate incontinence care to a female resident with multiple complex medical conditions, including type 2 diabetes mellitus, necrotizing fasciitis, chronic kidney disease, hypertension, and heart failure. The resident was cognitively intact, had an indwelling urinary catheter, and was dependent on staff for transfers and toileting due to her medical status. Facility records indicated that the resident required catheter care every shift and incontinence care every two hours or as needed. During an observed care episode, the CNA cleaned the resident's catheter, genital area, and groin, but neglected to clean the suprapubic area, which was folded with skin and required attention to prevent infection. The CNA admitted during an interview that she forgot to clean the suprapubic area due to nervousness, despite having received peri-care training two months prior. The Director of Nursing (DON) confirmed that the suprapubic area should have been cleaned during peri-care, especially given the skin folds present. Facility policy on perineal care emphasized the importance of cleanliness to prevent infections and skin irritation, specifically instructing staff to wash the perineal area. The failure to clean the suprapubic area as required constituted a lapse in proper incontinence and catheter care for the resident.
Improper Flushing Technique Used for Gastrostomy Tube
Penalty
Summary
A deficiency occurred when a nurse flushed a resident's gastrostomy tube by pushing 30 ml of water into the tube using a syringe plunger, rather than allowing the water to flow by gravity. The resident involved was an older male with severe cognitive impairment, dependent on a feeding tube for nutrition, and at risk for aspiration. The resident's care plan specified that tube feedings and flushes should be administered as ordered, with checks for placement and appropriate flushing to maintain hydration and tube patency. The physician's order required flushing the gastrostomy tube with specific amounts of water before and after medications. During observation, the nurse was seen using the plunger method to flush the tube, which was confirmed in an interview with the nurse, who acknowledged the error and stated that gravity should have been used. The Director of Nursing also confirmed that gravity should be used for flushing unless there is a blockage, in which case gentle plunger use may be considered. The facility did not have a policy regarding the use of gravity for tube feeding flushes.
Expired Medications Found on Medication Cart
Penalty
Summary
Surveyors observed that medication cart #1 on the 400 hall contained one bottle of Gentle Lax with an expiration date of 03/2025 and one bottle of Acetaminophen 500mg with an expiration date of 04/2025. These expired medications were not removed from the cart as required. During an interview, an LVN acknowledged missing the expiration dates and stated that administering expired medications would not be safe, as they could cause adverse reactions or be less effective. The Director of Nursing also confirmed that expired medications may not provide the intended therapeutic results or could potentially cause adverse reactions. A review of the facility's policy on "Medication Labeling and Storage" indicated that discontinued, outdated, or deteriorated medications should be returned or destroyed according to instructions from the dispensing pharmacy. The presence of expired medications on the medication cart demonstrates a failure to follow this policy and to provide pharmaceutical services that meet the needs of each resident.
Failure to Accurately Update Resident Medical Record with New Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by accepted professional standards. Specifically, a psychiatric physician added a diagnosis of general anxiety and prescribed diazepam 2 mg three times daily for anxiety, but this new diagnosis was not added to the resident's medical record. The resident's face sheet and electronic medical record did not reflect the updated diagnosis, despite the medication being ordered and administered for anxiety. The resident's medication administration record and physician orders confirmed the ongoing use of diazepam for anxiety, and the psychiatric physician's note documented the addition of the diagnosis. The Director of Nursing confirmed that the resident was receiving diazepam for anxiety and that the psychiatric doctor had added the diagnosis of general anxiety, but acknowledged that the facility did not update the medical record accordingly. It was noted that updating the medical record was the responsibility of the MDS nurse, but the facility did not have an MDS nurse at the time, which contributed to the inaccuracy. The facility's policy allowed for the use of electronic medical records, but the failure to update the diagnosis resulted in an incomplete and inaccurate medical record for the resident.
Improper Storage of Oxygen Cylinder in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored in a resident's room, contrary to the facility's policy which prohibits storing oxygen cylinders in any resident room or living area. The resident involved was an elderly female with a history of dysphagia, chronic pain, encephalopathy, hyponatremia, and a personal history of COVID-19. Her medical records indicated moderate cognitive impairment and a need for assistance with transfers. She had orders for oxygen therapy and nebulizer treatments due to respiratory failure. During an observation, a full oxygen cylinder was found in the resident's room. Interviews with the LVN and DON confirmed that the oxygen cylinder should have been stored in the designated oxygen storage room for safety reasons. The LVN was unaware of how long the cylinder had been in the room or why it was there, as the resident did not use it. Facility policy, as reviewed, clearly states that oxygen cylinders must be stored in racks, carts, or approved stands and never in resident rooms.
Resident Information Exposed Due to Unlocked Medication Cart Computer
Penalty
Summary
A medication cart was observed left unlocked and unattended in a hallway, with the computer screen on top of the cart displaying a resident's personal and medical information. The cart and exposed screen were visible and accessible to unauthorized individuals passing by. This incident involved a staff member, LVN A, who left the computer screen open and unattended, resulting in the exposure of confidential resident information. Upon returning to the cart, LVN A acknowledged forgetting to lock the computer screen and recognized that leaving it open constituted a HIPAA violation, as it could allow unauthorized access to resident information. The Director of Nursing (DON) confirmed that it was facility policy and expectation for staff to lock computer screens to prevent unauthorized disclosure of resident information, as outlined in the facility's Resident Rights policy.
Failure to Update Care Plan for Diet Order Change
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's current dietary needs. Specifically, the care plan for a male resident with a history of brain cancer, hemiplegia, and aphasia did not reflect a physician-ordered change from a pureed diet to a mechanical soft diet, despite the order being in place and the resident receiving the correct diet during meal service. The resident was moderately cognitively impaired, dependent on staff for eating, and required a mechanically altered diet, as documented in his assessments and physician orders. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for updating care plans. The Dietary Manager updated the meal ticket but was unaware of the need to update the care plan, while the LVN who received the diet order acknowledged she should have updated the care plan. The MDS Coordinator, responsible for auditing care plans, was not aware of the Dietary Manager's role in care plan updates. The facility's policy required care plans to be updated as resident conditions changed, but this was not followed in this instance.
Failure to Update Comprehensive Care Plan for Resident with Catheter and Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, to reflect the resident's current condition. Specifically, the care plan did not include the resident's use of an indwelling urinary catheter or the presence of a stage 4 pressure ulcer to the sacrum, despite these conditions being documented in the resident's medical records and orders. The resident had diagnoses including severe protein-calorie malnutrition, heart failure, respiratory failure, dysphasia, kidney failure, and urinary retention, and was cognitively intact. Orders for catheter care and wound care were present and active, but these interventions were not reflected in the care plan. Interviews with facility staff revealed that the MDS Coordinator was responsible for auditing and updating care plans, and the DON acknowledged that the care plan should have included the resident's wound and catheter. The omission was attributed to the care plan not being updated after the admission MDS assessment, which had triggered the need for these interventions. Facility policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within seven days of the comprehensive assessment, but this was not followed for the resident in question.
Failure to Follow Physician's Orders for Enteral Tube Flushing
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician's orders regarding the flushing of an enteral feeding tube for a resident with significant medical needs. The resident, a male with diagnoses including pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, gastroparesis, and gastrostomy status, was severely cognitively impaired and dependent on an enteral feeding tube for nutrition and medication administration. According to the physician's orders, the feeding tube was to be flushed with 30 ml of water before and after medication administration, and 10 ml between medications. During a medication pass, the LVN only flushed the tube with 10 ml of water prior to administering medications and 15 ml after, instead of the prescribed 30 ml. The LVN acknowledged forgetting to follow the correct flush amounts as ordered. The facility's policy and the Director of Nursing both confirmed the importance of adhering to the prescribed flush volumes to prevent tube clogging and ensure proper medication administration. The failure to follow the physician's orders constituted a deficiency in providing appropriate care for a resident with an enteral feeding tube.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on both the 200 and 300 halls were left unlocked and unattended on multiple occasions. On the 200 hall, a medication cart was found unlocked and unattended in the hallway, and the assigned LVN admitted to forgetting to lock it. The LVN acknowledged that leaving the cart unsecured could allow unauthorized persons to access medications, potentially leading to consumption of drugs not prescribed to them. On the 300 hall, the medication cart was also observed unlocked and unattended twice, and the assigned respiratory technician later locked it after being observed. The technician admitted to forgetting to lock the cart and recognized the risk of unauthorized access to respiratory and oxygen treatment medications. Interviews with staff, including the DON and unit manager, confirmed that facility policy requires medication carts to be locked when not in use to prevent unauthorized access, especially given the presence of residents who wander. Review of facility policy documents corroborated this expectation, stating that medication carts must be securely locked at all times when out of the nurse's view. The repeated failure to secure medication carts as required constituted a deficiency in the facility's medication storage practices.
Failure to Provide Required Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide special eating equipment, specifically an Adult Sip Cup, and appropriate assistance to a resident who required such adaptive devices for safe and effective meal consumption. The resident, a male with a history of malignant brain neoplasm, left-sided hemiplegia, and aphasia, was documented as being moderately cognitively impaired, dependent on staff for eating, and requiring a mechanically altered diet. Physician orders and the care plan specified the use of an Adult Sip Cup to assist with beverages and prevent spillage or choking. However, during observation, the resident was initially given regular cups by staff, resulting in repeated spillage while attempting to drink. The appropriate adaptive equipment was only provided later during the meal service after the resident had already experienced difficulty. Interviews with staff, including the ADON, dietary manager, CNA, and DON, confirmed that the resident was supposed to receive beverages in an Adult Sip Cup due to issues with dexterity and to prevent aspiration and dehydration. The facility's own policy required that adaptive devices be provided to residents who need them and that assistance be given to ensure residents can use and benefit from such equipment. Despite these documented needs and policies, the resident was not consistently provided with the required adaptive equipment at the start of the meal, leading to observed difficulties and spillage.
Failure to Ensure Safe Resident Transfers and Adequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, a female with hemiplegia, hemiparesis, age-related debility, lack of coordination, and an amputation below the left knee, was dependent on staff for transfers and had a history of being transferred via mechanical lift. On one occasion, she was transferred by two staff members without the use of a mechanical lift, despite her request and her usual transfer method. During this transfer, she was unable to bear weight, was lowered to the ground, and subsequently experienced pain and a distal femoral fracture, as confirmed by later imaging. Interviews revealed that the mechanical lift was not used because all lifts were occupied at the time, and staff deviated from the established transfer protocol. Another resident, a female with diabetes, dementia, and quadriplegia, required total assistance for transfers using a mechanical lift with two staff members. However, she was transferred by a single CNA using a mechanical lift, which resulted in the lift tipping over and the resident being dropped. The resident sustained a laceration and abrasion to her nose and was transported to the emergency room for evaluation. The facility's policy explicitly required two-person assistance for all mechanical lift transfers, and the CNA's action was unauthorized and against policy. Both incidents were confirmed through record reviews, staff and resident interviews, and facility documentation. The deficiencies were related to staff not following established protocols for safe resident transfers, either by not using the required mechanical lift or by not ensuring the mandated number of staff were present during a mechanical lift transfer. These failures resulted in injuries to both residents and demonstrated a lack of adequate supervision and hazard prevention in the resident environment.
Failure to Properly Investigate and Communicate Grievance Regarding Suspected Aerosol Use
Penalty
Summary
A resident with multiple complex medical conditions, including chronic respiratory failure requiring ventilator support, morbid obesity, myotonic muscular dystrophy, asthma, and spina bifida, reported a grievance after suspecting that an unknown staff member sprayed an unknown substance in her room. The resident, who was dependent on staff for all mobility and had intact cognition, stated she felt a mist on her arm but could not see who entered her room due to her physical limitations. She became upset when staff would not provide the name of the person who entered, leading her to call 911. The grievance was filed by a weekend supervisor on behalf of the resident and her family member, who also sought follow-up on the incident. The facility's documentation and investigation into the grievance were incomplete. The grievance form lacked signatures from the department head and did not include a response from the concerned party or indicate whether follow-up was required. The assigned social worker was unaware of the incident and had not spoken to the resident about it. The weekend supervisor interviewed one CNA who was present in the room but did not document the identity of the second, unknown staff member or her attempts to interview that person. The administrator and DON acknowledged the incident but could not identify the unknown staff member, and there was no evidence that the resident or her family received a written or verbal summary of the investigation or its findings, as required by facility policy. Interviews with staff revealed inconsistencies regarding who was present during the incident and whether any aerosol was used, despite facility policy prohibiting aerosols in resident rooms. The resident and her family reported that no one from the facility followed up with them about the outcome of the grievance. The facility's grievance policy requires prompt investigation, written and verbal communication of findings to the complainant, and documentation of actions taken, none of which were fully completed in this case.
Failure to Update Care Plan for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised by the interdisciplinary team after each assessment, specifically omitting the need for a mechanical lift for transfers. The resident, a female with hemiplegia, hemiparesis, age-related debility, lack of coordination, and an amputation below the left knee, was documented as dependent for transfers and cognitively intact. Despite multiple records indicating the use of a mechanical lift for transfers, the care plan only reflected supervision or limited to extensive assistance with one-person physical help, without specifying the mechanical lift requirement. Additional documentation and CNA assignment sheets did indicate the use of a mechanical lift, especially after dialysis when the resident was weaker. On a specific occasion, staff transferred the resident without a mechanical lift, despite her request and her history of being transferred this way for three years. The staff cited unavailability of mechanical lifts as the reason for not using one. Interviews revealed that the care plan was not updated to reflect the mechanical lift requirement, and the facility relied on CNA tracking lists due to the absence of an MDS nurse. The facility's policy required care plans to be updated after significant changes in condition, but this was not followed in this case.
Failure to Use Required PPE During Transfer of Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNAs) O and P failed to wear proper personal protective equipment (PPE) while transferring a resident who was on enhanced barrier precautions (EBP) due to a tracheostomy and dependence on a ventilator. During the transfer using a mechanical lift, both CNAs wore gloves but did not wear gowns, despite facility policy and signage indicating the need for gown and glove use for residents on EBP. The CNAs stated they were unaware that the resident was on EBP and believed the precautions and PPE were intended for the roommate. Both CNAs acknowledged receiving frequent infection control training but did not follow the required protocols during the observed transfer. The resident involved had significant medical needs, including quadriplegia, tracheostomy status, ventilator dependence, diabetes, and dementia, and required total assistance for activities of daily living. Facility policy specified that gown and glove use is required for high-contact care activities, such as transferring residents with indwelling medical devices under EBP. The Director of Nursing (DON) confirmed that the resident was on EBP due to the tracheostomy and acknowledged that staff should have worn gowns and gloves during the transfer, as outlined in the facility's infection prevention and control policy.
Respiratory Therapy Director Practiced Without Valid State License
Penalty
Summary
The facility failed to ensure that the Respiratory Therapy Director, who was working as a Respiratory Therapist, held a valid state license to practice in Texas during the period from August 2021 to August 2024. Review of the personnel file showed only a national certification and a state license effective beginning January 2025, with no evidence of a valid Texas license during the time the individual was employed in the role. The HR department head confirmed that only the national licensure was on file and did not see the need for state licensure. Additionally, a remedial plan from the Texas Board of Respiratory Care documented that the individual practiced without a state license during the specified period. Facility policy requires that personnel not perform duties requiring licensure until a current, unencumbered license is verified, which was not followed in this case.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse by a Certified Nursing Assistant (CNA), identified as CNA A, who provided rough bed mobility assistance and incontinent care. The incidents occurred on two separate occasions, during which CNA A was observed in video footage to handle the resident roughly, causing visible bruising. The resident, who was cognitively intact with a BIMS score of 15, reported feeling unsafe with CNA A and identified her as the source of his injuries. The resident's responsible party submitted videos and pictures showing the bruising, which were consistent with the rough handling observed in the videos. The resident, a male with significant physical and intellectual disabilities due to genetic conditions, was dependent on staff for toileting hygiene and lower body dressing. He was always incontinent and used a wheelchair. Despite his impairments, he was social and engaged in activities like bingo. The resident's care plan indicated he required assistance with activities of daily living and was known to become upset easily. However, the facility failed to ensure that staff approached him in a calm and reassuring manner, as outlined in his care plan. Interviews with staff revealed that CNA A had been assigned to the resident during the week of the incidents and had documented providing care on the days in question. Despite being trained on resident rights and abuse prevention, CNA A's actions were deemed abusive by the facility's Director of Nursing (DON) after reviewing the video footage. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the failure to protect the resident from rough handling and the subsequent emotional distress reported by the resident.
Failure in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in missed doses of critical seizure medications and improper administration of a PRN medication. Specifically, the resident did not receive five doses of Lamictal and two doses of Phenobarbital over a two-day period. Additionally, Ativan, which was prescribed for seizures, was administered for agitation and anxiety instead, contrary to the physician's orders. The resident, a male with a history of tracheostomy, unspecified dementia, schizophrenia, anxiety disorder, and seizures, was admitted to the facility shortly before the deficiencies occurred. The facility's Medication Administration Record (MAR) indicated that the resident missed several doses of his prescribed medications, and there was no documentation explaining these omissions. Furthermore, the MAR showed that Ativan was given for agitation, despite the order specifying its use for seizures, and there was no documentation of seizure activity to justify its administration. Interviews with facility staff, including LPNs and the DON, revealed confusion and lack of clarity regarding the administration of medications. The DON acknowledged that medications might not have been available due to specialty or insurance issues, but was unsure of the exact reasons. The facility's policies required staff to verify unclear orders with prescribers and to contact them if medications were unavailable, but these procedures were not followed, contributing to the deficiencies observed.
Privacy Breach During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of two residents during personal care activities, leading to a deficiency in maintaining resident privacy and dignity. Resident #2, who is cognitively intact and requires assistance with activities of daily living due to cerebral cysts, was observed on video having his incontinence brief changed without the privacy curtain being fully closed. This exposed his lower body to his roommate, Resident #3, and potentially to the camera installed in the room. The camera, authorized by Resident #2's responsible party, was not obstructed during perineal care as required, leading to a breach of privacy. Resident #3, who has mild cognitive impairment and is highly hearing impaired, was also affected by the privacy breach. The facility did not have a signed consent for electronic monitoring for Resident #3, and his image was captured on the camera without proper authorization. The facility's social worker and administration were aware of the camera's presence but failed to ensure that Resident #3's privacy was protected, as his responsible party was not informed about the need for consent. Interviews with facility staff, including the CNA involved and the Director of Nursing, revealed that there was a lack of adherence to privacy protocols during personal care. The CNA did not close the privacy curtain, and the facility's policies on dignity and videotaping were not followed, resulting in the exposure of residents' private areas and the unauthorized capture of images. The facility's failure to maintain privacy during care and to obtain necessary consents for electronic monitoring contributed to the deficiency.
Failure to Implement Comprehensive Care Plan Due to Insurance Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs. The resident, a 61-year-old male with a history of cerebral infarction and age-related physical debility, was admitted to the facility and required assistance with activities of daily living due to cognitive and physical impairments. Despite having an active order for physical, occupational, and speech therapy evaluation and treatment, the resident did not receive these services due to issues related to insurance approval. The resident's care plan indicated a need for rehabilitation therapy screening, but the facility did not ensure that the resident was assessed for physical and occupational therapy as planned. The resident's interdisciplinary screen recommended referrals to therapy services, but these were not acted upon due to the resident's Medicaid pending status and lack of insurance coverage. The facility's Director of Rehabilitation (DOR) and Director of Nursing (DON) acknowledged that the resident had not received therapy services and cited insurance approval as a barrier, with no documentation of therapy assessments by physical and occupational therapy staff. Interviews with the resident and their responsible party (RP) revealed dissatisfaction with the lack of therapy services, and the RP expressed concerns about the resident's declining physical condition. The facility's policy on therapy services required physician orders, but there was no clear process for handling therapy referrals when insurance approval was delayed. The facility's failure to provide necessary therapy services and implement a comprehensive care plan placed the resident at risk of not receiving the care needed to address their specific needs.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident as required by their comprehensive plan of care. The resident, a 61-year-old male with a history of cerebral infarction and age-related physical debility, was admitted to the facility and had an active physician order for evaluations and treatments by physical therapy (PT), occupational therapy (OT), and speech therapy (ST) dated several months prior. Despite these orders, the resident did not receive the necessary evaluations and treatments, which could place him at risk of a decline in his physical capabilities. Interviews and record reviews revealed that the resident had not received PT, OT, or ST services due to issues related to insurance approval. The Director of Rehabilitation (DOR) stated that the resident was not referred to PT or OT initially because he was Medicaid pending and did not have insurance coverage. The resident's responsible party (RP) expressed concerns about the lack of rehabilitation services and noted that the resident had become weaker since admission. The facility's process for therapy orders involved insurance review first, and therapy screening depended on the resident's insurance type. The facility's policy on therapy services required orders to be obtained from the resident's attending physician, but there was no clear process for handling therapy referrals or treatment orders. The DOR admitted that PT and OT staff did not document or complete screens or assessments for the resident, and the DON was unsure if a policy existed for therapy orders. The facility's failure to provide the necessary rehabilitative services as ordered by the physician highlights a deficiency in their process for ensuring residents receive appropriate care.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an LPN administered medications intended for another resident. The medications included atorvastatin, labetalol, and hydralazine, which were not prescribed for the resident. This incident occurred during the evening medication pass, and the error was realized by the LPN partway through the administration process. The resident involved was a female with a complex medical history, including anoxic brain damage, chronic respiratory failure with hypoxia, and secondary hypertension. She was not assessed for mental status due to communication difficulties and was receiving nutrition through a feeding tube, along with oxygen therapy and tracheostomy care. Her prescribed medications included anticoagulants, antiplatelets, and anticonvulsants, none of which were the medications mistakenly administered. The error was documented in the resident's progress notes, and the facility's policies on medication administration were not followed, as the LPN did not verify the resident's identity or check the medication label three times as required. The incident was reported to the physician and the resident's family, and the resident was monitored for any adverse reactions, although none were noted. The facility's policy on adverse consequences and medication errors defines such errors as the administration of drugs not in accordance with physician orders or professional standards.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A and CNA B during the care of a resident on Enhanced Barrier Precautions (EBP). On the specified date, LVN A and CNA B did not wear gowns while providing wound care and peri-care to the resident, despite the resident's status requiring such precautions. The resident, who was admitted with multiple diagnoses including anoxic brain damage and dependence on a ventilator, had orders for EBP due to the presence of indwelling devices and a skin integrity issue. During the observed care, LVN A did not adhere to proper infection control practices. She failed to change gloves or perform hand hygiene throughout the procedure, even after touching potentially contaminated surfaces and the resident's wound. LVN A used the same piece of gauze multiple times to clean the wound and did not change gloves after handling soiled dressings. Additionally, she touched various medical devices and the resident's body without changing gloves, increasing the risk of cross-contamination. Interviews with the staff revealed a lack of awareness and understanding of EBP requirements. CNA B was unaware that the resident was on EBP and believed that the use of gowns was optional. LVN A admitted to deviating from her training due to being in a hurry and acknowledged her failure to follow proper procedures. The Director of Nursing (DON) confirmed the infection control issues upon reviewing the video footage, highlighting the need for staff to wear gowns and adhere to hand hygiene protocols during high-contact care activities.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the right to personal privacy during personal care for four residents. Observations revealed that staff did not adequately close privacy curtains, doors, or blinds while providing incontinence care. This lack of privacy was noted during care for residents with various medical conditions, including hypertension, diabetes, tracheostomy status, and cognitive impairments. The failure to provide privacy was observed during specific instances of care, such as checking for incontinence and providing incontinent care. Resident #5, who has severe cognitive impairment and is incontinent of bowel and bladder, was checked for incontinence by a CNA who did not pull the privacy curtain or close the blinds. Similarly, Resident #6, who has intact cognition and requires bowel and bladder incontinence care, was provided care by a CNA who did not completely close the privacy curtain. Resident #7, with severe cognitive impairment and a catheter, was checked for incontinence by an RN who left the door and blinds open and did not fully close the privacy curtain. Resident #8, with severe cognitive impairment and a catheter, received incontinent care from two CNAs who did not fully close the privacy curtain. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the facility's policy requires privacy curtains, doors, and blinds to be closed during resident care to protect residents' privacy. Staff acknowledged the importance of maintaining privacy to prevent residents from feeling embarrassed or ashamed. The facility's policies on resident rights, perineal care, and dignity emphasize the importance of treating residents with respect and ensuring their privacy during personal care.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by state and federal laws. During an observation and interview, it was found that the Respiratory Treatment Cart #1 on the 300 hall was left unlocked and unattended. The Director of Nursing (DON) confirmed that the cart was not supposed to be left unlocked, even though it contained only respiratory supplies such as tracheostomy equipment. This oversight occurred in an environment where mobile residents were present, increasing the risk of unauthorized access. Additionally, the Wound Treatment Cart #2 was observed to be left unlocked on two separate occasions by an LVN. The cart contained various treatments, including creams and ointments, which could potentially be ingested by residents, leading to adverse reactions. The LVN acknowledged that the cart should not have been left unlocked, especially with mobile residents in the facility. The DON reiterated the expectation that all medication and treatment carts should be locked when unattended to prevent unauthorized access and potential harm.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal and incontinent care for seven residents. Observations revealed that staff members did not change gloves or perform hand hygiene at critical points during care, such as after removing soiled briefs or before handling clean items. For instance, a CNA was observed dropping a clean brief on the floor, picking it up without changing gloves, and placing it in a resident's drawer. Another staff member washed hands for only 8 seconds after checking a resident for incontinence, contrary to the recommended 20 seconds. Several residents with various medical conditions, including diabetes, respiratory failure, and cognitive impairments, were affected by these practices. The care plans for these residents indicated the need for assistance with activities of daily living and incontinence care. However, staff members were observed not adhering to infection control guidelines, such as failing to perform hand hygiene between glove changes and using the same surface of wipes repeatedly during perineal care. Interviews with staff and the Director of Nursing (DON) revealed a lack of adherence to infection control policies. Staff members expressed confusion about proper glove use, with some believing double gloving was acceptable. The DON admitted to not knowing the facility's hand hygiene policy and acknowledged that double gloving was not acceptable. The Administrator emphasized the importance of following infection control policies to reduce exposure to infections, yet the observations indicated a systemic failure in implementing these practices.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment. The deficiency was identified for one of the eight residents reviewed for care plans. The care plan did not address several critical areas, including cognitive loss/dementia, visual function, communication, urinary incontinence and indwelling catheter, psychosocial well-being, activities, nutritional status, feeding tube, dehydration/fluid maintenance, pressure ulcer, physical restraints, and functional abilities related to self-care and mobility. The resident in question was admitted with multiple diagnoses, including type 2 diabetes, hypertension, nontraumatic intracerebral hemorrhage, and acute/chronic respiratory failure, among others. The comprehensive MDS assessment revealed that the resident had severely impaired cognitive skills for daily decision-making and was dependent on assistance for various activities of daily living. The resident also had an indwelling catheter, was always incontinent of bowel, required a feeding tube, and was at risk of developing pressure ulcers. Despite these needs, the care plan only focused on an actual fall incident, neglecting other significant care areas. Interviews with facility staff, including an RN and the DON, revealed that the care plan was not completed in a timely manner following the MDS assessment. The RN acknowledged the importance of completing care plans to ensure that all staff are aware of the plan of care and can appropriately care for the residents. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of completing the MDS assessment, but this was not adhered to in this case.
Failure to Maintain Sanitary Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents requiring tracheostomy care, as observed during a survey. For both residents, the aerosol tubing connected to their tracheostomies was found on the floor. In the case of the first resident, the tubing was picked up by a CNA and placed on a side table, after which an LVN reconnected it to the resident's tracheostomy without being informed that it had been on the floor. Similarly, for the second resident, the tubing was also found on the floor, picked up, and placed on a side table by a CNA, and subsequently reconnected by the same LVN without knowledge of its prior location. Interviews with the staff revealed a lack of communication regarding the tubing's contamination, which is crucial for preventing infection. The CNA involved admitted to not informing the LVN about the tubing being on the floor, acknowledging the importance of replacing it to maintain sanitary conditions. The LVN stated that had she been aware of the tubing's contamination, she would have ensured it was replaced. The facility's Director of Nursing expressed an expectation for staff to report such incidents due to the risk of infection. The facility's policy on tracheostomy care emphasizes maintaining cleanliness to prevent infection, which was not adhered to in these instances.
Failure to Document Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had a suprapubic catheter. On 9/29/24, a Licensed Vocational Nurse (LVN A) inserted a suprapubic catheter for the resident but did not document the procedure or the urine output in the medical records. The resident, a 22-year-old male with a history of neuromuscular dysfunction of the bladder and quadriplegia, was admitted to the hospital with gross hematuria and a malfunctioning suprapubic catheter. Despite the resident's report and the LVN's acknowledgment of the catheter change, the documentation was missing, which is against the facility's policy requiring all services and changes in a resident's condition to be recorded. Interviews revealed that LVN A had the competencies for suprapubic catheter insertion but failed to document the procedure due to a busy night. The Director of Nursing (DON) confirmed that major events like catheter insertions should be documented, and if another nurse was present, they should have recorded the procedure in the progress notes. Another nurse, LVN D, checked on the resident throughout the shift and confirmed urine output, but this was also not documented. The lack of documentation could lead to a lack of continuity in care and diminished quality of life for the resident.
Improper Catheter Bag Handling Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the improper handling of a catheter bag for a resident. The resident, a cognitively intact female with a history of type 2 diabetes, urinary tract infections, and end-stage renal disease, was observed with her catheter bag lying on the floor instead of being anchored to the bed rail. This observation was made during a survey, and it was noted that the catheter bag contained no urine, although there was urine present in the tubing. The resident reported that the morning staff did not consider it their responsibility to empty the catheter bag, although the evening and night shifts did not have this issue. Interviews with the facility's staff, including an LVN and the DON, confirmed the improper placement of the catheter bag on the floor, which was acknowledged as a potential infection control issue. The LVN, who was the charge nurse for the day shift, admitted that the nursing staff was responsible for ensuring the catheter bag was properly anchored, but could not explain why the bag was on the floor. The DON also confirmed that the bag was anchored during her check but could not explain the discrepancy. The facility's policy on catheter care, revised in September 2024, clearly stated that catheter tubing and drainage bags should be kept off the floor.
Failure to Label Open Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in their kitchen. During an observation of the reach-in refrigerator, two open gallon jugs of ranch dressing were found unlabeled. The Dietary Manager confirmed that all food items should be labeled with the date opened and the use-by date after being opened, as per the facility's policy. This policy, named Food Receiving and Storage, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. The Dietary Manager stated that staff are trained to follow this procedure, and it is their responsibility to ensure compliance. The failure to label the food items placed residents at risk for foodborne illness, as it did not comply with the Food Code standards set by the U.S. Public Health Service and the FDA.
Inaccurate Blood Pressure Documentation in EMAR
Penalty
Summary
The facility failed to maintain accurate medical records for five residents, specifically in documenting blood pressure readings when administering hypertension medication. The discrepancies were found in the electronic medical administration records (EMAR) where the same blood pressure readings were recorded for different shifts on the same day. This inconsistency was noted for residents who were on metoprolol tartrate, a medication used to treat hypertension, with specific instructions to hold the medication if systolic blood pressure (SBP) was less than 110 or pulse was less than 60. The residents involved had various levels of cognitive impairment, with some being cognitively intact and others moderately impaired. Each resident had a care plan that included monitoring blood pressure and notifying the physician if readings were high or low. However, the documentation in the EMAR did not reflect accurate blood pressure readings, which could potentially lead to medication errors and affect the continuity of care. Interviews with the nursing staff revealed that they took their own vital signs and recorded them on paper before entering them into the computer system. Some staff admitted to using the 'use last documented' button in the electronic system, which led to repeated blood pressure readings being recorded. The Director of Nursing (DON) and the Administrator acknowledged the issue and noted that the repeated use of the same blood pressure readings did not accurately reflect the effectiveness of the medications administered.
Inadequate Care Plan for Resident with Restraints
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was inconsistent with the resident's rights and did not describe the services necessary to attain or maintain the resident's highest practicable well-being. The resident, a male with a history of cerebral infarction, tracheostomy status, anxiety disorder, and schizophrenia, had an order to remove his mitten restraints every two hours for ten minutes for skin checks and exercises. However, the care plan only documented a requirement to visually observe the mitten restraints every two hours, without including the necessary intervention to release the restraints for skin checks or exercises. Observations and interviews revealed that the nursing staff were following the physician's order to remove the restraints every two hours, despite the care plan's incorrect documentation. The LVN confirmed that she removed the restraints one at a time to check the resident's skin and perform finger exercises, while the DON acknowledged the discrepancy between the care plan and the actual practice. The facility's policy on comprehensive assessments indicated that significant errors in assessments could result in inappropriate care plans, which was evident in this case.
Inadequate Supervision and Security Measures for Residents at Risk of Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for several residents identified as at risk for elopement. Resident #5, who was admitted with dementia and assessed as a high wander risk, managed to leave the facility unsupervised and was found 13 miles away. The facility's front door was left unlocked and unmonitored during specific hours, and the receptionist was unaware of which residents were at risk for wandering or elopement. Residents #7, #10, #11, and #12 were also assessed as at risk for wandering, yet the facility did not have adequate measures in place to monitor them. The front door was unlocked and unmonitored during certain hours, and the receptionist did not have a list of residents who required supervision when going outdoors. Observations revealed that residents were able to leave the facility unsupervised, posing a risk of harm. Interviews with staff indicated a lack of awareness and training regarding the supervision of residents at risk for elopement. The facility's policy on elopement was not effectively implemented, as evidenced by the unlocked doors and the absence of a system to monitor residents at risk. This lack of supervision and security measures led to the identification of an Immediate Jeopardy situation, highlighting the potential for severe injury or death.
Failure to Document Meal Consumption
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of meal consumption on two consecutive days. The resident, who was cognitively intact and totally dependent on assistance for eating, did not have records indicating that meals were provided on 3/9/24 and 3/10/24. Interviews with staff revealed that the meals were given but not documented due to the involvement of agency staff who were not fully oriented to the facility's documentation methods. The resident's care plan and physician's orders specified a no-added-salt diet with regular texture and consistency, and the resident required total assistance for feeding. Despite these clear instructions, the lack of documentation created confusion about whether the resident was fed. The weekend supervisor and agency staff failed to document the meals, and there were no notes indicating that the resident refused to eat on those dates. Interviews with the Director of Nursing (DON) and other staff confirmed that the resident was fed but the documentation was missing. The DON acknowledged that the agency staff and weekend supervisor did not document the feeding in the Point of Care (POC) system. This lapse in documentation was attributed to the agency staff not being fully trained in the facility's documentation procedures, leading to potential misinformation about the resident's care.
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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