Dfw Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 900 W Leuda St, Fort Worth, Texas 76104
- CMS Provider Number
- 455881
- Inspections on file
- 62
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 63 (4 serious)
Citation history
Health deficiencies cited at Dfw Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, schizophrenia, and other psychiatric and neurological conditions, who was on multiple psychotropic meds and receiving psych and psych NP services, was issued a 30‑day discharge notice for behavioral reasons without clear clinical documentation that his needs could not be met in the facility or that he posed an unmanageable danger. Facility records showed intermittent behaviors, including medication refusals, yelling, room entry, and two physical incidents, with 1:1 monitoring and med adjustments but no documented evaluation of intervention effectiveness and no state incident report for a resident‑to‑resident altercation. The facility obtained an OPC to send the resident to an inpatient behavioral hospital and, after his psychiatric stabilization, refused readmission while discharge planning and communication with the hospital, a proposed group home, and the resident’s RP were inconsistent and conflicting, resulting in an unsafe and poorly coordinated transfer and discharge process.
Two residents with moderate cognitive impairment and psychiatric diagnoses engaged in a verbal and physical altercation after staff failed to effectively separate and de-escalate them, resulting in one resident sustaining a facial laceration that required hospital treatment.
A resident with severe cognitive impairment alleged that a nurse hit her during a shower, but the facility did not conduct a thorough investigation, failed to implement protective measures during the process, and did not maintain required documentation or report findings as mandated by state law and facility policy.
A resident's diagnosis of dementia was not accurately transcribed into the medical record, despite supporting documentation from hospitals and a physician. This omission led to incomplete records and contributed to the resident being able to leave the facility unsupervised, with staff unaware of the resident's absence. Interviews revealed that the process for entering diagnoses was inconsistent and not always completed promptly, resulting in gaps in care planning and documentation.
A resident with severe cognitive impairment and multiple medical conditions was subjected to repeated physical abuse by another resident with a history of aggressive behavior and psychiatric diagnoses. Despite documented risks and prior incidents, interventions such as 1:1 monitoring and safety checks did not prevent further assaults, resulting in actual harm and visible injuries to the abused resident.
A resident with severe cognitive impairment and multiple medical conditions was the victim of repeated assaults by another resident. Despite positive trauma screening results and ongoing behavioral concerns, the facility did not provide or refer the resident for behavioral health services or psychological assessment after the incidents. Staff interviews confirmed that no behavioral health interventions were initiated, and the resident's family observed increased withdrawal following the abuse.
A resident with schizophrenia and moderate cognitive impairment was immediately discharged to a behavioral hospital due to escalating violent behavior. Although the family was notified by phone, the ombudsman was not provided written notification of the transfer or discharge, and there was no documentation of attempted contact. Facility staff were unaware of the missed notification, and required discharge policies were not followed.
A female resident with severe cognitive impairment and a history of dementia was found partially undressed and confused in a male resident's room, who was cognitively intact and had a history of inappropriate behaviors. The male resident had previously attempted to enter other residents' rooms and was noncompliant with staff, but effective interventions were not implemented. The female resident was unable to consent, and staff and family confirmed her vulnerability. The facility failed to protect her from sexual abuse, despite documented warning signs and prior incidents.
The facility did not develop or implement comprehensive care plans addressing sexual activity and relationships for multiple residents, despite staff awareness of these relationships and interactions. Care plans lacked measurable objectives and interventions related to sexual behavior, and staff actions regarding consent and safe sex were not consistently documented or formalized in care plans.
A resident with cognitive impairment and a history of substance use alleged that another resident put drugs in her drink, leading to a hospital visit and police involvement. Despite staff and leadership being aware of the allegation, the incident was not reported to authorities within the required timeframe, as facility leaders believed there was insufficient evidence and questioned whether the event occurred on facility grounds.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, resulting in incomplete planning and documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Nursing staff did not ensure that ordered laboratory tests, including CBC, CMP, lipid panel, Valproic acid, Hgb, and A1C, were obtained as scheduled for a resident with multiple medical conditions. There was no documentation of the labs being completed or refused, despite facility policy requiring completion and documentation of all physician orders.
A resident with dementia and a history of sexually inappropriate behavior was admitted without adequate care planning or interventions to address his behaviors. The resident inappropriately touched a student visitor, and staff and other residents reported ongoing discomfort and incidents, but facility leadership did not conduct a full investigation or report the incident as required. Staff were not properly trained or in-serviced on handling such behaviors, and interventions were inconsistently applied, resulting in a failure to protect residents and visitors from potential abuse.
A resident with dementia and a history of sexually inappropriate behaviors was admitted without a care plan addressing these issues. The resident engaged in inappropriate conduct toward staff, other residents, and a student visitor, causing discomfort and concern among others. Facility leadership did not recognize or act on the resident's history, failed to investigate or report incidents as required, and did not provide staff with adequate training or interventions to manage the behaviors, resulting in an Immediate Jeopardy situation.
A resident with multiple medical and behavioral conditions, including moderate cognitive impairment and a history of drug use, was able to obtain and use marijuana within the facility, resulting in an overdose and hospitalization. Despite prior knowledge of drug-related behaviors and reports from residents and staff about ongoing drug use, facility leadership did not implement effective supervision, investigation, or reporting measures, and there was no care plan addressing substance abuse for the resident.
Two residents with complex medical and behavioral histories did not have comprehensive, individualized care plans addressing all identified needs, including behaviors and substance abuse, despite documented incidents and staff awareness. Care plans were not updated to reflect significant changes or new behaviors, contrary to facility policy and regulatory requirements.
Two residents were involved in separate incidents that were not reported to the state agency or law enforcement as required. One resident with dementia and a history of sexually inappropriate behaviors inappropriately touched a student visitor, and the event was not reported despite staff and resident concerns. Another resident was found with signs of drug overdose and tested positive for marijuana, with prior concerns about drug use and distribution in the facility, but this was also not reported. The facility's leadership acknowledged awareness of these issues but did not initiate required investigations or reporting.
The facility did not thoroughly investigate or respond to allegations of abuse and drug use involving two residents. One resident with a history of sexually inappropriate behavior was not properly care planned or monitored, leading to an incident involving a student visitor that was not fully investigated or reported. Another resident was suspected of bringing drugs into the facility and was hospitalized for overdose, but no investigation or reporting occurred. Staff and other residents reported ongoing concerns, but the facility failed to follow its own policies for investigation and reporting.
Two residents with mild cognitive deficits and behavioral histories were placed together as roommates, resulting in a physical and verbal altercation that was not immediately reported or assessed by staff. The facility failed to prevent and promptly address resident-to-resident abuse, and no post-incident skin assessments were documented.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with grease buildup, leaking pipes, and makeshift repairs using towels. Staff and management confirmed ongoing plumbing issues and delays in repair, and cleaning documentation was not provided as required by facility policy.
A large, uncovered hole behind the kitchen wall, left open during ongoing plumbing repairs, along with leaking sinks and dirty towels, resulted in an unsanitary kitchen environment. Staff interviews confirmed the hole was left open while awaiting the plumber's return, and the kitchen sewer system would flood when the sink was drained. These conditions placed residents at risk of exposure to infectious materials.
A resident with dementia and multiple mental health conditions was transferred to a behavioral hospital due to escalating behaviors. The facility did not provide timely written notification of the transfer or discharge to the resident's representative or the ombudsman, and the resident was unable to understand the notice due to cognitive impairment. Facility policies did not address the requirement for written notification to representatives.
A resident with moderate cognitive impairment and a history of trauma was involved in a physical altercation with the Administrator, who pushed the resident, resulting in a fall. The incident was not reported or documented until after surveyor intervention, and required notifications to the DON, corporate office, and state agencies were delayed, in violation of facility policy.
A resident with moderate cognitive impairment and multiple medical conditions was able to leave the facility unsupervised, as staff did not have interventions in place for wandering or elopement. The resident was last seen walking around the facility, was later found outside in cold weather without proper clothing, and required emergency medical attention after being returned to the facility.
A resident with schizophrenia and moderate cognitive impairment physically assaulted a staff member and the Administrator after feeling threatened by the Administrator's approach. The incident was not documented, reported, or uploaded to the state portal as required, and the DON was not informed until the following day by a family member. The Administrator, responsible for incident reporting, failed to complete the necessary reports or notifications.
A resident with schizophrenia and moderate cognitive impairment was involved in a physical altercation with the Administrator after being approached in a manner perceived as aggressive. The required incident/accident report was not completed on the day of the event, and there was no documentation in the resident's progress notes or assessments. The report was only initiated the following day after direction from the DON, and it remained incomplete, with missing notifications and documentation.
Two residents at the facility had inaccurate MDS assessments, leading to deficiencies in their care plans. One resident, with chronic kidney disease, had a discharge MDS that did not reflect his dialysis treatment, despite regular transport for it. Another resident, with COPD, had a quarterly MDS that failed to include his continuous oxygen therapy, despite consistent administration. Interviews with staff revealed acknowledgment of these documentation errors, highlighting the importance of accurate MDS records for comprehensive care.
The facility's kitchen failed to label and date food items in the reach-in refrigerator, including shredded cheese, sandwiches, and sliced ham, risking food-borne illnesses. Interviews with staff revealed non-compliance with the facility's food storage policy due to staffing issues.
A medication aide in a long-term care facility failed to follow infection control protocols while administering medications to a resident. The aide did not perform hand hygiene after checking the resident's blood pressure and used a bare finger to remove a tablet from a medication cup. Additionally, the aide administered eye drops without wearing gloves. These actions were not in compliance with the facility's infection control policies, as confirmed by the DON and ADM.
The facility failed to ensure a safe environment in the resident smoking courtyard by improperly storing a propane grill with two gas tanks, posing a fire hazard. Despite claims that the tanks were empty, a test showed the grill could ignite. Staff interviews confirmed the grill's use during a recent event, acknowledging the risk of fire or explosion. The facility's fire safety policy was not followed, contributing to the unsafe conditions.
A resident with hypertension was administered Nifedipine without proper blood pressure parameters, while Carvedilol was held due to a misunderstanding of the threshold. The medication aide failed to verify parameters with a nurse, leading to a deficiency in pharmaceutical services. The facility's policy on medication administration was not followed, contributing to the error.
A resident with multiple health conditions was administered Amiodarone 200 mg without checking vital signs, despite a warning to hold the medication if the heart rate was below 60 BPM. The administering MA was unaware of the requirement, and interviews with facility staff revealed a lack of clarity regarding the necessity of checking vital signs before administering heart medications.
A resident with a complex medical history experienced a fall and showed signs of increased lethargy and altered mental status, but the LTC facility failed to notify the physician and the resident's family. Despite staff observations of the resident's declining condition, the facility did not follow its policy to report significant changes, placing the resident at risk of not receiving immediate medical attention.
A resident with significant medical conditions, including hemiplegia and visual loss, did not have a call light within reach, as observed during a survey. Despite the care plan's intervention to ensure call light accessibility, it was found underneath the bed, out of reach. Staff interviews revealed that CNAs are responsible for ensuring call lights are accessible, but this was not adhered to, leading to a deficiency in care.
A resident with a history of hemiplegia, hemiparesis, and seizures was not provided with a fall mat as required by their care plan, despite being at risk for falls. The facility's staff, including the charge nurse and DON, were unaware of the omission, which was contrary to the facility's care plan policy requiring comprehensive, person-centered care plans.
A resident with extensive ADL needs did not receive scheduled bed-baths, going up to a week without proper hygiene care. Staffing shortages and inadequate documentation contributed to the issue, with the resident reporting disrespectful treatment by staff. The facility's policies for scheduled showers and timely responses were not followed, leading to this deficiency.
A resident with hemiplegia and hemiparesis was found without a call light within reach, and a fall mat was not provided as per the care plan. The resident, at risk for falls and with moderate mental impairment, was unable to communicate needs due to the call light being out of reach. Staff interviews revealed a lack of awareness and adherence to the care plan, despite facility policies requiring call light accessibility.
The facility failed to ensure proper incontinent care and catheter orders for three residents, who had indwelling urinary catheters without a physician's order. This oversight could introduce infection control issues.
Failure to Justify Discharge and Ensure Safe, Coordinated Transfer for Psychiatric Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was not transferred or discharged unless the transfer or discharge was necessary for the resident’s welfare, that the resident’s needs could not be met in the facility, or that the safety or health of others was endangered, and the failure to implement an effective discharge planning process. The resident was an adult male with Parkinsonism, seizure disorder, anxiety, depression, and schizophrenia, with a BIMS score of 03 indicating severe cognitive impairment and fluctuating delirium. His MDS and care plan documented mood issues, isolation, and a history of behaviors, including two prior aggressive incidents toward other residents, but also reflected that he had no documented ongoing physical or verbal aggression at the time of the 12/01/25 assessment. He was on multiple psychotropic medications and received psychological and psychiatric services, with a psychological note on 12/11/25 indicating no current risk factors for self-injury, sexual acting out, homicidal, or aggressive behavior, and describing him as engaged and interactive in therapy. Despite this, on 12/12/25 the facility issued a 30‑day discharge notice citing that the safety and health of other individuals were endangered and that the resident’s needs could not be met. The clinical record did not contain clear documentation that his needs could not be met in the facility or that he posed a danger that could not be managed through care planning or IDT interventions. Nursing notes from December 2025 through early February 2026 documented periodic behavioral concerns such as medication refusals, yelling, wandering into other residents’ rooms, verbal altercations, and two physical incidents: a shoulder bump of the maintenance director on 12/26/25 and pushing another resident on 01/12/26. The facility placed him on 1:1 monitoring after these events and notified the PMHNP, who adjusted his antipsychotic medication, but the nursing documentation did not reflect evaluation of the effectiveness of the increased antipsychotic dose or that identified behavioral interventions had been exhausted or found ineffective. The facility also did not report the 01/12/26 resident‑to‑resident physical aggression to the state incident system (TULIP). The facility then obtained an Order of Protective Custody and sent the resident to an inpatient behavioral hospital for psychiatric evaluation and stabilization, with the ADM stating the OPC was obtained because they “needed him out as soon as possible” and believed he was on the verge of harming someone. The resident’s RP reported not being informed of the transfer beforehand, not consenting to the transfer or discharge, and not being aware of any group home plan, while the SW and ADM described efforts to find alternate placement and a group home, and stated that the final decision not to accept the resident back after psychiatric hospitalization was made by the ADM. The behavioral hospital’s Director of Clinical Services reported that the facility had issued a 30‑day discharge notice, that the resident had been stabilized with no violent incidents for several days prior to an attempted discharge, and that the nursing facility communicated it would not accept the resident back, despite the resident still being legally their resident and without providing clear discharge planning assistance. Conflicting accounts and poor coordination among the facility, the behavioral hospital, the group home agency, and the RP resulted in the resident being discharged from the behavioral hospital without confirmed placement and being returned when a purported group home was found to be vacant. The surveyors found that the facility failed to ensure a safe and orderly transfer and discharge process and refused to readmit the resident after inpatient psychiatric stabilization, without adequate documentation that his needs could not be met or that he posed an unmanageable danger, and without an effective discharge planning process focused on his discharge goals and continuity of care.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. One resident, a female with moderate cognitive impairment and multiple psychiatric diagnoses, had a documented history of aggressive and inappropriate behavior towards other residents, including physical aggression and use of racial slurs. Her care plan noted risks for bleeding and bruising due to aspirin use, and previous incidents had required staff intervention to separate residents and assess for injuries. The other resident, a male also with moderate cognitive impairment and psychiatric diagnoses, similarly had a history of socially inappropriate and provocative behavior, including ramming his wheelchair into others. On the day of the incident, both residents encountered each other near the smoking area, exchanged words, and the female resident provoked the male resident by grabbing his pants and using racial slurs. Multiple staff members observed escalating verbal aggression, but the residents were not effectively separated or de-escalated before the situation became physical. The altercation resulted in the female resident sustaining a laceration above her eye, which required hospital treatment. Interviews with staff and residents revealed that the altercation involved both verbal and physical aggression, with the female resident striking the male resident and the male resident using his cane in self-defense, leading to the injury. The facility's failure to prevent the altercation, despite both residents' known behavioral risks and prior incidents, constituted a deficiency in ensuring residents' right to be free from abuse. Staff interviews indicated that while some attempts were made to separate and redirect the residents, these measures were not sufficient to prevent the physical confrontation and resulting injury.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse, protect residents during the investigation, and report the results of the investigation as required by state law. A resident with a history of major depressive disorder, anxiety, mood disorder, and schizophrenia, and with severely impaired cognition, reported that a nurse hit her while she was in the shower. The facility did not initiate an immediate investigation or implement protective measures for the resident or others while the allegation was being reviewed. Documentation showed that the resident became agitated during a shower, called staff names, threw objects, and refused assistance, eventually lying naked on the floor and repeatedly requesting to be sent to the hospital. Staff were unable to examine her for injuries or obtain vital signs due to her refusal to be touched. The nurse contacted the medical director, who ordered the resident to be sent to the hospital for further evaluation. There was no evidence that the facility conducted a thorough investigation into the abuse allegation or took steps to prevent further potential abuse during this period. Interviews with staff and review of facility records revealed that the required Post-Incident Report (PIR) and other investigation documentation were missing. The DON and administrator were unable to provide the PIR or any additional investigation records, citing that the previous administrator had not left the necessary paperwork. The facility's own abuse policy requires immediate reporting, thorough investigation, and documentation of all findings, none of which were completed or available for review in this case.
Failure to Accurately Transcribe and Maintain Resident Diagnoses
Penalty
Summary
The facility failed to accurately transcribe and maintain complete medical records for a resident, specifically omitting a diagnosis of dementia from the resident's records. The resident's face sheet and other clinical documentation did not reflect the dementia diagnosis, despite multiple sources, including hospital records and documentation from the resident's physician, indicating the presence of dementia. The omission was confirmed through interviews with facility staff, including the MDS coordinator and DON, who acknowledged that the diagnosis was not entered into the database prior to the incident and that the information was only uploaded after being provided by the resident's family. The deficiency was further highlighted when the resident, who had a history of cognitive impairment and a BIMS score indicating moderate impairment, was able to leave the facility unsupervised. The family was notified by a hospital that the resident had been there for two hours, while the facility receptionist was unaware of the resident's absence and initially reported the resident as present and fine. The facility's process for determining which residents require supervision when leaving the building relied on assessments and documentation that were incomplete due to the missing diagnosis. Interviews with staff revealed inconsistencies and a lack of clarity regarding the process for transcribing admitting diagnoses and updating resident records. The MDS coordinator and DON both indicated that the failure to enter the dementia diagnosis was due to missing or unreviewed paperwork at the time of admission. The facility's own policy required that all relevant medical information be documented promptly to ensure proper care planning, but this was not followed in the case of this resident, resulting in incomplete and inaccurate records.
Failure to Prevent Repeated Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and dementia, from repeated physical abuse by another resident with a history of aggressive behaviors and severe cognitive impairment. The abused resident, who was independently ambulatory and had no behavioral symptoms, was subjected to three separate incidents of physical assault by the same peer. These incidents included being hit on the back of the head, being struck and subsequently falling to the ground, and being hit in the face, resulting in visible bruising, redness, and swelling. In one instance, the resident required evaluation at a local hospital, and in another, a facial x-ray was ordered due to the injuries sustained. The aggressor resident had a documented history of impulse control disorder, bipolar disorder, and other psychiatric and neurological diagnoses. Despite previous aggressive incidents, including hitting another resident and swinging a chair at staff and equipment, the interventions implemented by the facility, such as 1:1 monitoring and hourly safety checks, were not sufficient to prevent further assaults. The care plans for both residents acknowledged the risk of behavioral disturbances and the need for close observation, but the measures in place did not effectively prevent repeated abuse. Interviews with staff and family confirmed that the abused resident became more withdrawn following the incidents, and there was concern for her safety. The facility's policies required the protection of residents from abuse by anyone, including other residents, and mandated staff training in abuse prevention and management of aggressive behaviors. However, the repeated incidents of resident-to-resident abuse demonstrated a failure to ensure the resident's right to be free from abuse, as required by both facility policy and federal regulations.
Failure to Provide Behavioral Health Services After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who was the victim of three separate incidents of resident-to-resident abuse. The resident, an elderly female with diagnoses including Alzheimer's disease, severe cognitive impairment, major depressive disorder, and chronic medical conditions, was assaulted on three occasions by another resident. Despite these incidents, there was no evidence that the resident received a psychology consultation or assessment following any of the assaults. Record reviews showed that the resident had a history of cognitive impairment and behavioral issues, such as intruding on others' privacy and taking personal items, but was not documented as having behavioral symptoms on her MDS. After each assault, interventions included 1:1 monitoring and trauma-informed screenings, which revealed positive responses indicating trauma. However, no referrals for psychological evaluation or therapy were made, even though the trauma screenings indicated the resident had experienced distress related to the assaults. Interviews with facility staff, including the social worker and DON, confirmed that no behavioral health referrals were initiated for the resident after the incidents. Staff cited the resident's advanced dementia and previous refusals of other services as reasons for not pursuing psychological services. The administrator stated that behavioral health services should be offered after such incidents, but this was not done. Family members reported the resident became more withdrawn after the abuse, but no behavioral health interventions were provided.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide written notification to the ombudsman regarding the transfer and subsequent discharge of a resident to a behavioral hospital. The resident, who had diagnoses including schizophrenia, unspecified psychosis, and major depressive disorder, was admitted with moderate cognitive impairment. Due to an escalation in verbal, physical, and violent behavior towards staff, the facility initiated an immediate discharge and transferred the resident to a hospital for psychological evaluation. Although the family member was notified by phone, the resident, who was his own responsible party, refused to give verbal consent for the discharge. Documentation review revealed that the social worker (SW) claimed to have contacted the ombudsman by leaving a voicemail regarding the immediate discharge, but there was no documentation of this action, nor could the SW provide a date for the attempted notification. Additionally, the SW could not produce a copy of the original 30-day notice or confirm its delivery. The ombudsman later confirmed that no notification was received before or after the resident's discharge. Interviews with facility staff, including the DON and ADM, indicated that they were unaware the ombudsman had not been properly notified. The facility's policy requires notification of the ombudsman for all discharges, but this was not followed in this instance. The lack of written notification to the ombudsman constituted a failure to ensure the resident's rights regarding transfer and discharge were upheld.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a female resident with severe cognitive impairment and a history of Alzheimer's disease, dementia, and stroke was not protected from sexual abuse by another resident. The female resident, who had a BIMS score of 3 indicating severely impaired cognition and was only sometimes able to be understood, was found in a male resident's room without underwear or pants, confused, and unable to walk unassisted. The male resident, who was cognitively intact with a BIMS score of 14 and a history of traumatic brain injury, depression, and drug use, was found in the same room with his pants and underwear down to his thighs. Staff discovered the situation after the female resident was reported missing from her room and a search was conducted. Prior to the incident, the male resident had exhibited concerning behaviors, including attempting to enter female residents' rooms, refusing redirection, and being noncompliant with staff instructions. These behaviors were documented in progress notes, but there was no evidence of effective interventions or increased supervision to prevent further incidents. The male resident's care plan included monitoring for sexually inappropriate behavior, but did not address his drug use or provide specific strategies to prevent access to vulnerable residents. The female resident's care plan noted her tendency to intrude on others' privacy and her cognitive limitations, but did not include interventions related to sexual safety or protection from other residents. On the morning of the incident, staff were unable to locate the female resident during routine rounds and initiated a search. She was eventually found in the male resident's room, disoriented and partially undressed, with physical signs of injury including a swollen lip and bruising. Interviews with staff and family members confirmed that the female resident was unable to make informed decisions or consent to sexual activity, and that the male resident had a history of inappropriate and threatening behavior. The facility failed to implement adequate protective measures despite documented warning signs, resulting in the sexual assault of a vulnerable resident.
Failure to Develop Comprehensive Care Plans for Resident Sexual Activity
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing sexual activity and relationships for several residents, despite evidence of known sexual relationships and interactions among residents. Specifically, five residents with varying degrees of cognitive impairment and mental health diagnoses were identified as being involved in sexual relationships or behaviors, yet their care plans did not include measurable objectives, timeframes, or interventions related to sexual behavior or relationships. The care plans reviewed either omitted this aspect entirely or only addressed unrelated behavioral issues. Interviews with staff, including the DON, ADON, and MDS Coordinator, revealed that while staff were aware of consensual sexual relationships among residents and sometimes provided education on consent and safe sex, these interactions were not consistently documented or care planned. Staff described providing privacy and condoms to residents they believed were capable of consenting, but there was no evidence of formal assessments or care plan interventions to guide staff actions or ensure resident needs were met in this area. Some staff believed care plans were in place, but upon review, these were either missing or incomplete regarding sexual activity. The facility's policy on care planning required the development of individualized, comprehensive care plans based on resident assessments, with input from the interdisciplinary team and, when possible, the resident and their representatives. However, the policy did not specifically address acute care plans for issues not covered by the comprehensive assessment, such as sexual relationships. As a result, the lack of care planning for known sexual activity among residents represented a failure to meet regulatory requirements for comprehensive, person-centered care planning.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, as required by federal regulations. Specifically, a resident alleged that another resident put drugs in her beer, which led to her experiencing chest pain and being sent to the hospital. Despite the seriousness of the allegation, the facility did not report the incident to Health and Human Services within the required timeframe. The Director of Nursing (DON) and Administrator were both aware of the allegation but chose not to report it, citing the absence of evidence from hospital tests and the belief that the incident did not occur. The events leading to the deficiency involved two residents with complex medical and psychosocial histories. The resident making the allegation had diagnoses including bipolar disorder, anxiety, COPD, and a history of substance use and cognitive impairment. She reported feeling unwell after consuming a drink provided by another resident and subsequently called 911, resulting in police and ambulance involvement. Documentation shows that staff, including nurses and the ADON, were aware of the allegation and the resident's subsequent hospital visit, but the required abuse report was not made to the state agency. Interviews with facility leadership revealed a lack of clarity and consistency in handling the allegation. The DON admitted that the report was not made because hospital tests were negative, while the Administrator believed the incident occurred off-site and therefore did not require reporting. Both leaders demonstrated uncertainty about reporting requirements and failed to document their decision-making process. The facility's policy required reporting all allegations of abuse within the federally mandated timeframe, but this was not followed in this case.
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 absence of a comprehensive approach to care planning, as required, and was observed through review of the resident's records and care documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Obtain and Document Ordered Laboratory Tests
Penalty
Summary
Nursing staff failed to ensure that laboratory tests ordered by the physician were obtained as scheduled for a resident with multiple complex medical conditions, including metabolic encephalopathy, severe protein-calorie malnutrition, anemia, type 2 diabetes mellitus, bipolar disorder, and paranoid disorder. Specifically, orders for CBC, CMP, lipid panel, and Valproic acid to be drawn every six months, as well as Hgb and A1C every three months, were not carried out as required. Review of the resident's electronic clinical record revealed missing lab results for the specified periods, with no documentation to indicate that the labs were either completed or refused by the resident. The Director of Nursing (DON) confirmed that there was no evidence in the record to show that the blood draws were performed or refused, despite the resident's known history of refusing care and becoming combative. Facility policy requires that all physician orders, including labs, be completed as ordered and that refusals be documented. The lack of documentation and failure to obtain the ordered labs resulted in the deficiency cited by surveyors.
Failure to Prevent and Address Resident's Sexually Inappropriate Behaviors
Penalty
Summary
The facility failed to ensure a resident was free from abuse, neglect, and exploitation, specifically by not providing appropriate interventions and services to address the resident's ongoing sexually inappropriate behaviors. The resident, a male with dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, had a documented history of sexually inappropriate behavior at a previous facility, including recommendations for placement in a male-only locked unit. Upon admission, the facility did not care plan for these behaviors, and staff were unaware of the resident's history, despite clinical notes indicating prior sexual aggression. The deficiency was further evidenced when the resident inappropriately touched a student visitor during an activity, an incident that was reported to the DON and Administrator. However, the facility did not conduct a full investigation, report the incident to the state agency, or notify law enforcement. Interviews with other residents and staff revealed ongoing discomfort and reports of sexually inappropriate behaviors by the resident toward both staff and other residents, which had been reported to facility leadership without effective intervention. The care plan was not updated in a timely manner, and interventions such as 1:1 supervision were inconsistently implemented and not maintained. Additionally, the facility's abuse prevention policies and staff training were insufficient to address the specific risks posed by the resident's behaviors. Staff were not in-serviced on abuse/neglect and sexually inappropriate behaviors following the incident, and there was a lack of documentation and communication regarding interventions. The facility's failure to identify, investigate, and implement effective measures to prevent further incidents placed residents and visitors at risk of harm.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psych consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent and Address Resident Sexual Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement effective written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with a history of sexually inappropriate behaviors. This resident, who had diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, was admitted without a care plan addressing his known sexually inappropriate behaviors. Despite documentation from a previous facility recommending placement in a male-only locked unit due to sexual aggression, the facility did not initially identify or address these behaviors upon admission. The resident engaged in sexually inappropriate conduct, including inappropriately touching a student visitor during an activity, making female residents uncomfortable with sexual gestures, and repeatedly being sexually inappropriate with staff. Multiple residents and staff reported feeling uncomfortable or unsafe due to the resident's actions, and these concerns were communicated to facility leadership. However, the facility did not implement effective interventions or services to address the resident's behaviors, nor did they in-service staff on how to properly handle such behaviors to prevent further incidents. The facility's leadership, including the DON and Administrator, failed to recognize or act upon the resident's history and ongoing behaviors. They did not conduct a full investigation or report the incident involving the student to the state agency or law enforcement, as required by policy. Additionally, the facility's abuse prevention policy was not fully implemented, and staff were not adequately trained or informed about handling sexually inappropriate behaviors beyond routine or initial training. These failures resulted in an Immediate Jeopardy situation, as residents and visitors were placed at increased risk for abuse and neglect.
Removal Plan
- The DON, Social Services Director, and designee(s) interviewed/assessed all residents for potential abuse by conducting safe surveys on each resident.
- Resident evaluated by primary care provider and provided a medication update.
- Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted. Psyche consult provided.
- Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible.
- IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions.
- Care plan revisions and interventions communicated to front line staff caring for resident.
- Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident.
- Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes.
- Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies.
- Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting.
- Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect.
- DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Process will be ongoing.
- In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Process will be ongoing.
- The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. In-service will be ongoing.
- QAPI meeting will be held monthly, and findings discussed.
- The DON will monitor the effectiveness of interventions will be ongoing.
- A pre/posttest on abuse and neglect will be ongoing.
- The facility is still looking for proper placement of resident.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Prevent Resident Drug Use and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple complex medical and behavioral diagnoses, including COPD, multiple sclerosis, bipolar disorder, and legal blindness. The resident had a moderate cognitive impairment and required partial to moderate assistance with most activities of daily living. Despite being on parole for drug use and a sex offense, and after staff were informed by the resident's parole officer that he was bringing drugs into the building to sell to other residents, the facility did not implement effective interventions to prevent further incidents. The resident was found exhibiting signs of an overdose, including weakness, limpness, pinpoint pupils, confusion, and difficulty talking, and was subsequently transported to the hospital, where he tested positive for marijuana. Prior to this event, the resident had failed drug screenings, and the facility was aware of ongoing concerns about drug use among residents, as reported by multiple residents and staff. The facility did not have a care plan addressing the resident's behavior related to substance abuse, and there was no evidence of a thorough investigation or reporting to the state agency when drug use was suspected or confirmed. Interviews with residents and staff revealed that the smell of marijuana and reports of drug use were common, particularly during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not take sufficient action to investigate, report, or prevent the introduction and use of nonprescription drugs within the facility. The facility's policy prohibited illegal drug use, but it was not effectively enforced, and staff were not in-serviced on recognizing or reporting signs and symptoms of drug use prior to the incident.
Removal Plan
- Resident #2 was assessed for signs or symptoms of drug use. MD was notified. Resident was drug tested.
- All residents will be in-serviced on the facility policy regarding illegal drug use.
- All residents will be assessed upon return from any leave from the facility for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking.
- All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy.
- The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete.
- Resident is being discharged pending acceptance.
- The DON/designee will monitor the effectiveness of assessments completed of residents.
- QAPI meeting will be held and findings will be discussed.
- A pre/posttest will be completed by staff on signs/symptoms of drug use and ongoing.
- Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulatory standards. For the first resident, who had multiple diagnoses including dementia, metabolic encephalopathy, COPD, diabetes, chronic respiratory failure, end-stage renal failure, and hypertension, the admission Minimum Data Set (MDS) assessment did not identify any physical or verbal behaviors. However, the resident had a history of socially inappropriate behaviors, specifically sexually inappropriate behavior, which was not addressed in the care plan upon admission. The care plan was only revised later to include interventions for these behaviors, indicating a delay in recognizing and planning for the resident's needs as identified in the comprehensive assessment. For the second resident, who had diagnoses including COPD, multiple sclerosis, bipolar disorder, and legal blindness, the care plan did not address the resident's substance abuse history or related behaviors. Despite documentation in progress notes that the resident was involved in bringing drugs into the facility and had an incident requiring transfer to the emergency room due to drug use, there was no corresponding care plan to address these behaviors. The resident himself admitted to a history of heavy drug use and recent marijuana use, and staff were aware of the incident and the ongoing risk, but this was not reflected in the care planning process. Interviews with facility staff, including the DON and MDS Nurse, confirmed that care plans were not updated to reflect significant changes or incidents, such as the emergence of new behaviors or substance abuse. The staff acknowledged the importance of updating care plans to ensure all care needs and interventions are communicated and implemented, but in these cases, the care plans did not include measurable objectives or timeframes to address the identified needs. This failure to update and individualize care plans was inconsistent with facility policy and regulatory requirements, as outlined in the facility's own policies and the CMS RAI Manual.
Failure to Timely Report Alleged Abuse, Neglect, and Drug-Related Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than two hours after the allegation was made, as required by federal and state regulations. Specifically, two residents were involved in separate incidents that were not reported to the state agency or law enforcement as required. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors inappropriately touched a student visitor during an activity. Despite being aware of the incident, the DON and Administrator did not report the event to the state agency, citing uncertainty about the details and lack of clear evidence from camera footage. Interviews with staff and residents revealed ongoing concerns about the resident's sexually inappropriate behaviors, which had been reported to facility leadership but not adequately addressed or reported. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was found exhibiting signs of a drug overdose and was transported to the hospital, where he tested positive for marijuana. Prior to this event, there were documented concerns about the resident bringing drugs into the facility to sell to others, and a 30-day discharge notice had been issued due to non-compliance. Despite these concerns and the positive drug test, the facility did not report the incident to law enforcement or the state agency. Interviews with residents and staff indicated ongoing issues with drug use within the facility, with reports of marijuana and other substances being used during smoke breaks and in resident rooms. The Administrator and DON acknowledged awareness of these issues but did not initiate investigations or report the incidents as required. The facility's policy on abuse prevention requires the investigation and reporting of any allegations of abuse within the required timeframes. However, in both cases, the facility failed to follow established procedures for reporting suspected abuse, neglect, or exploitation. The lack of timely reporting and investigation of these incidents could place residents at risk for continued abuse or harm due to unaddressed allegations.
Failure to Investigate and Respond to Allegations of Abuse and Drug Use
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of abuse, neglect, and exploitation for two residents. In the first case, a male resident with dementia and a history of sexually inappropriate behaviors was admitted without a care plan addressing these behaviors. Despite documentation from a previous facility recommending placement in a male-only secured unit due to sexual aggression, the facility did not implement appropriate interventions upon admission. The resident later inappropriately touched a student visitor during an activity, but the incident was not fully investigated or reported to the state agency. Staff and other residents reported ongoing sexually inappropriate behaviors, and the resident was only placed on Q15-minute monitoring after the incident. The Administrator reviewed camera footage but did not see conclusive evidence and therefore did not proceed with a full investigation or report the incident, despite policy requirements. In the second case, another male resident with multiple diagnoses, including bipolar disorder and legal blindness, was suspected of bringing drugs into the facility and selling them to other residents. The resident was found exhibiting signs of overdose and was sent to the hospital, where he tested positive for marijuana. Despite prior knowledge of the resident's behavior and reports from staff and other residents about drug use in the facility, there was no care plan addressing substance abuse. The facility did not initiate a thorough investigation or report the incident to the state agency. The Administrator and DON were aware of ongoing concerns about drug use, including the smell of marijuana during smoke breaks and packages suspected of containing THC, but did not take investigative or reporting actions. The facility's policy required investigation and reporting of all allegations of abuse, neglect, and exploitation, but these procedures were not followed in either case. Staff were not in-serviced on recognizing or reporting signs of drug use after the incidents, and there was no evidence of comprehensive investigations into the allegations. The lack of timely and thorough investigation and failure to implement effective interventions placed all residents at increased risk for abuse and neglect, as directly stated in the report.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse, as evidenced by an incident in which the two roommates engaged in a physical and verbal altercation. Both residents had mild cognitive deficits, with one having a history of physical aggression towards staff and the other having a care plan addressing her relationship with a male companion. Despite these behavioral histories, the residents were placed together as roommates, which ultimately led to conflict. On the day of the incident, one resident was exiting the shared bathroom as the other attempted to enter, resulting in an exchange of words and a physical struggle where they grabbed each other's arms and hands. The altercation was not immediately reported to staff; instead, the residents resolved the issue themselves and only disclosed the event two days later. Interviews with another resident and review of incident reports indicated a pattern of previous verbal and physical altercations involving one of the residents. The facility's documentation revealed that no skin assessments were performed for either resident following the incident, and the care plans did not address the risk of resident-to-resident altercations. The facility's policy guarantees residents the right to be free from abuse and neglect, but the failure to prevent and promptly address the altercation between the two residents constituted a deficiency in protecting residents from abuse.
Deficient Kitchen Sanitation and Plumbing Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to improper storage, preparation, and cleanliness of food service areas. Grease buildup was noted on the wall and floor behind the air fryer and stove, and towels that had turned brown were found wrapped around leaking pipes and under the pots and pans sink. Water was observed running into a hole where a pipe did not fit properly, and staff interviews confirmed that the pipes had been leaking for some time. The dietary manager and cook acknowledged ongoing plumbing issues and the use of towels to control water leakage, with maintenance and an outside plumber involved but repairs delayed. Documentation of cleaning schedules and staff assignments was requested but not provided before surveyor exit. Facility policy requires the kitchen and dining areas to be kept clean and sanitary, with regular cleaning schedules and staff training, but observations and interviews indicated these standards were not being met. A plumber's estimate and investigation confirmed that the kitchen sewer floods the floor when the three-compartment sink is drained, further contributing to unsanitary conditions.
Uncovered Kitchen Repair Hole and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen area. Observations revealed a large, uncovered hole behind the kitchen wall, which had been dug by a plumber two weeks prior to address issues with the kitchen's plumbing. The hole remained uncovered because the plumber had not yet returned to complete the repairs, and the Maintenance Director (MD) stated that the hole was left undisturbed in anticipation of the plumber's return. Additionally, the kitchen environment was found to have leaking sinks and dirty towels, further contributing to unsanitary conditions. Interviews with facility staff confirmed that the plumber was responsible for the ongoing repairs and that the kitchen sewer system would flood the floor when the three-compartment sink was drained. The plumber's estimate indicated that the best option to prevent contamination was to cover the hole when work was not being performed, but this had not been done. The failure to cover the hole and address the unsanitary conditions in the kitchen could expose residents to infectious materials.
Failure to Provide Timely Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to a resident's representative and the ombudsman, as required. Specifically, a resident with multiple mental health diagnoses, including dementia and schizoaffective disorder, was transferred to a behavioral hospital due to escalating verbal, physical, and violent behaviors. Although the resident received a discharge notification, her moderate cognitive impairment and dementia rendered her unable to understand the notice. The resident's representative and the ombudsman did not receive written notification prior to the transfer; the ombudsman only received verbal notification on the day of the transfer and written notification several days later. Attempts to contact the resident's representative were unsuccessful at the time of the transfer. Review of facility policies revealed that neither the Admission, Transfer, and Discharge Register Policy nor the Unmanageable Residents Policy included requirements for providing written notification of transfer or discharge to the resident's legally authorized representative. The deficiency was identified through interviews and record review, which confirmed that the required notifications were not provided in writing and in a manner understood by the resident or her representative prior to the transfer.
Failure to Protect Resident from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect a resident from abuse, specifically from a physical and verbal altercation with the Administrator. On the date of the incident, the Administrator pushed the resident, causing the resident to fall. The event was not reported or documented until after surveyor intervention the following day. The Administrator was not suspended until after the surveyor's involvement, and there was no immediate notification to the appropriate authorities or documentation in the resident's records regarding the incident. The resident involved had a history of schizophrenia, diabetes, and unspecified psychosis, with a moderate cognitive impairment as indicated by a BIMS score of 12. The resident's care plan identified a risk for altered status due to traumatic life experiences, particularly with male authority figures, and included specific interventions to reduce triggers. Despite these documented risks and interventions, the incident occurred and was not properly reported or documented in the resident's progress notes, assessments, or incident/accident reports. Interviews with staff and family members confirmed the altercation and the lack of timely reporting and documentation. Facility policy required that all occurrences affecting resident welfare, safety, or health be reported to appropriate agencies within 24 hours and that allegations of abuse be thoroughly investigated and reported. However, the Administrator, who was also the abuse coordinator, did not follow these policies, as the incident was not reported to the DON, corporate office, or state agencies in a timely manner. The Ombudsman and other required parties were not notified until after surveyor intervention, and the incident was not entered into the facility's reporting systems as required by policy.
Removal Plan
- Resident #1 was assessed by the Nurse.
- A thorough investigation was initiated by the Corporate Office and Director of Nursing Services.
- The Medical Director was notified by the DON.
- The DON called and left a message for the Ombudsman.
- The Responsible Party (RP) was notified by the Administrator.
- The accused Team Member was placed on Administrative Leave pending investigation.
- The Police Department was called and arrived at the facility.
- The Incident Report was completed.
- The SIMS was initiated.
- In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded), De-escalation of aggressive behaviors and resident to staff altercations.
- The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test.
- TEXAS Abuse hotline number posted in strategic areas within the facility, staff made aware of postings.
- Supervisor Rounds have been started to interview residents for issues related to care, respect and dignity.
- The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form.
- An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement.
- The Corporate Nurse Team will conduct a Zoom meeting with the Director of Nursing. The purpose of the in-service is to provide education for the following areas: Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director, Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse, Conducting Education and Training with all Departments, Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication, Five day follow up with the State Office.
- The Director of Nursing Services, or designee, will conduct a random audit of five residents weekly for four consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities.
- Findings of this audit will be reviewed in the Resident Council meetings.
- This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met.
Resident Elopement Due to Inadequate Supervision and Lack of Elopement Interventions
Penalty
Summary
A resident with a history of hyperlipidemia, schizophrenia, depression, anxiety disorder, parkinsonism, epilepsy, and unspecified behaviors, and who had a BIMS score indicating moderate cognitive impairment, was not provided with adequate supervision and assistance devices to prevent accidents. The resident's care plan did not reflect any wandering behaviors, and there was no indication that interventions for elopement risk were in place prior to the incident. On the date of the incident, overnight staff observed the resident walking around the facility and attempting to urinate in inappropriate places. The resident continued to wander and was last seen at 5:10 AM. Staff were unable to locate the resident during their rounds and initiated a search. The ADON was notified, and a code yellow was called. Despite searching the building and surrounding area, the resident was not immediately found. The police were notified, and staff continued searching outside the facility. The resident was eventually found by a staff member three blocks from the facility, barefoot and without a jacket, in cold weather conditions. Upon return, the resident was shivering, had very cold skin, and was nonverbal. The police called emergency medical services, and the resident was transported to the emergency room, where he was diagnosed with a viral upper respiratory infection and had an elevated blood pressure. There were no alarms heard by the ADON upon arrival, and the incident report confirmed the resident had eloped from the facility.
Failure to Timely Report Resident-to-Staff Physical Altercation
Penalty
Summary
The facility failed to immediately report an incident involving a resident with schizophrenia and moderate cognitive impairment who physically assaulted a staff member and the Administrator. The incident occurred when the resident, who had a history of being triggered by certain authority figures, felt threatened by the Administrator's approach and responded with physical aggression. Despite the occurrence, there was no incident or accident report completed, and no documentation of the event was found in the resident's records for the date in question. Additionally, the incident was not uploaded to the Texas Unified Licensing Information Portal as required. The Director of Nursing (DON) was not informed of the incident until the following day, after a family member reported it. The DON stated she was not responsible for incident reporting or uploading information to the state system, indicating that this was the Administrator's responsibility. However, the Administrator did not complete the required reports or notifications. As a result, the incident was not reported to the appropriate authorities in a timely manner, and there was a lack of documentation and communication regarding the event within the facility.
Failure to Timely Complete and Document Incident Report Following Resident Altercation
Penalty
Summary
The facility failed to ensure a complete and accurate incident/accident report was completed for a resident involved in a verbal and physical altercation with the Administrator. The incident occurred when the resident, who has a history of schizophrenia, diabetes, and moderate cognitive impairment, was approached by the Administrator in a manner the resident perceived as aggressive, leading to the resident physically striking the Administrator and subsequently falling to the floor. The resident's care plan indicated a risk for altered status due to past traumatic experiences and specified interventions for staff to follow, including calm approaches and contacting a family member if needed. Despite these interventions, there was no incident/accident report completed on the day of the event, nor was there documentation in the resident's progress notes or assessments regarding the incident. The incident report was only initiated the following day after the DON instructed the LVN to complete it, and it remained incomplete with missing notifications to agencies or people. Interviews with staff confirmed that the report should have been completed in the EHR under the resident's name on the same day as the incident, and the DON acknowledged that the responsible nurse is expected to document such incidents immediately or before leaving for the day. There was also no specific policy on documentation of incident reports in residents' medical records.
Inaccurate MDS Assessments for Dialysis and Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #1, a male with chronic kidney disease and dependent on dialysis, had a discharge MDS assessment that did not reflect his ongoing dialysis treatment. Despite having MD orders for dialysis on specific days, this critical information was omitted from his MDS, potentially impacting his continuity of care. Interviews and record reviews confirmed that Resident #1 was regularly transported for dialysis, yet this was not documented in his discharge assessment. Similarly, Resident #5, a male with COPD and other respiratory conditions, had a quarterly MDS assessment that failed to include his continuous oxygen treatment, as ordered by his physician. The resident's care plan and TARs indicated consistent administration of oxygen therapy, yet this was not captured in the MDS. Observations and interviews with Resident #5 confirmed the daily use of oxygen, highlighting the discrepancy in the MDS documentation. Interviews with the MDS/LVN and DON revealed acknowledgment of these documentation errors. The MDS/LVN admitted to missing the documentation of critical treatments for both residents, while the DON emphasized the importance of accurate MDS records for ensuring comprehensive care. The facility's failure to accurately document these treatments in the MDS assessments could lead to inconsistencies in care and potential risks for the residents involved.
Failure to Properly Label and Store Food in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Items in the reach-in refrigerator were not labeled with the name of the contents, use-by date, or expiration date. Specific items observed included a metal pot with shredded cheese covered by a ceramic plate, a Styrofoam plate with potato chips and two sandwiches, a block of cheese wrapped in plastic, a metal pan with meat pies covered in plastic wrap, and a metal pan with sliced ham that was uncovered. These lapses in labeling and covering food items could potentially lead to food-borne illnesses and contamination. Interviews with facility staff, including the Dietary Manager, DON, and Administrator, revealed a lack of compliance with the facility's policy on food storage. The Dietary Manager acknowledged that outside food should not be stored in the facility refrigerator and emphasized the importance of labeling and dating food to prevent food-borne illnesses. The DON confirmed that the expectation was for all food to be labeled, dated, and properly covered. The Administrator attributed the oversight to staffing issues, noting that kitchen staff had difficulty retaining employees, which led to missed procedures. The facility's policy, dated 2017, clearly stated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA A) during the administration of medications to a resident. The resident, a cognitively intact female with multiple diagnoses including anxiety disorder, breast cancer, and hypertension, was observed during a medication pass. MA A did not perform hand hygiene after checking the resident's blood pressure and before handling medications. He used his bare finger to remove a Coreg tablet from the medication cup, which he then discarded, and failed to perform hand hygiene afterward. Additionally, MA A administered eye drops to the resident without wearing gloves, further breaching infection control protocols. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that MA A's actions were not in compliance with the facility's infection control policies. The facility's policies require staff to perform hand hygiene before and after medication administration and to use gloves when administering eye drops. The facility's policy on administering medications and standard precautions emphasizes the importance of following infection control procedures to prevent the transmission of diseases and infections. These lapses in protocol could potentially place residents at risk of infectious diseases and cross-contamination.
Fire Hazard in Resident Smoking Area Due to Improper Grill Storage
Penalty
Summary
The facility failed to maintain a safe environment in the resident smoking courtyard, where a propane grill with two gas tanks was improperly stored. Observations revealed that one propane tank was attached to the grill, while another was positioned behind it. Despite claims from the Maintenance Director that the tanks were empty, a test showed that the grill could ignite, indicating the presence of gas. This situation posed a significant fire hazard, especially in an area where residents were permitted to smoke. Interviews with facility staff, including the Activity Director, Maintenance Director, CNA, Activity Assistant, Administrator, and DON, confirmed the presence of the grill and its use during a recent facility event. The staff acknowledged the potential risk of fire or explosion due to the propane tanks being connected to the grill. The facility's policy on fire safety and prevention, which requires flammable items to be stored in a locked metal cabinet, was not adhered to, further contributing to the unsafe conditions in the smoking area.
Failure in Pharmaceutical Services for Blood Pressure Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of blood pressure medications. The resident, a cognitively intact female with a history of high blood pressure among other conditions, was prescribed Nifedipine and Carvedilol for hypertension. During a medication observation, a medication aide (MA A) administered Nifedipine but held Carvedilol due to the resident's blood pressure reading of 105/72, which was below the perceived threshold of 110. However, the medication aide did not realize that Nifedipine was also a blood pressure medication and should have been held as well. The medication aide admitted to not verifying the blood pressure parameters with a nurse, which could have prevented the administration error. The Licensed Vocational Nurse (LVN C) confirmed that neither medication had specified parameters for holding based on blood pressure readings. The Director of Nursing (DON) stated that the perceived parameter of 110 was a misunderstanding, as it was actually the ICD code for hypertension. The DON also mentioned that the physician did not require parameters for administering blood pressure medications, and the pharmacists advised that checking blood pressure before administration was unnecessary. The Medical Director was informed of the missing parameters and subsequently implemented a standing order with parameters for all blood pressure medications. The facility's policy on medication administration emphasized the importance of verifying medication details and consulting with the prescriber if there were concerns about potential adverse effects. Despite this, the medication aide did not follow the policy, leading to the deficiency in pharmaceutical services.
Failure to Check Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and appropriate accessory and cautionary instructions. This deficiency was observed in the case of a resident who was administered Amiodarone 200 mg without checking vital signs or heart rate, despite a warning on the medication bubble card to hold the medication if the heart rate was less than 60 BPM. The medication was administered by MA B, who was unaware of the requirement to check the resident's heart rate before administration. The resident involved was an elderly female with multiple diagnoses, including atrial fibrillation, type 2 diabetes, and high blood pressure, among others. The resident had severe cognitive impairment, as indicated by a BIMS score of 3 out of 15. During the medication observation, MA B administered the medication without checking the resident's blood pressure and heart rate, stating that the parameters on the bubble pack were from an old prescription and that she was unaware of the current heart rate requirement. Interviews with facility staff, including an LVN and the DON, revealed that there was an expectation for staff to check vital signs before administering heart medications. However, there was a lack of clarity and communication regarding the necessity of checking vital signs, as the DON mentioned that the physician did not require BP parameters for medication administration. The Medical Director later acknowledged the missing parameters and emphasized the importance of checking vital signs before administering such medications.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who had a fall and showed signs of increased lethargy and altered mental status. Despite the resident's complex medical history, including encephalopathy, sickle cell, diabetes, stroke, and liver cirrhosis, the facility did not notify the physician or the family about the fall or the resident's declining condition. Interviews and record reviews revealed that the resident was admitted to the facility with a baseline of lethargy and moderate cognitive impairment. Throughout the week, the resident's condition deteriorated, with increased lethargy and decreased responsiveness. Staff members, including nurses and CNAs, observed these changes but failed to report them to the physician. The resident's family was also not informed of the changes, learning about the fall from the resident's roommate instead. The facility's policy required staff to notify the physician and the resident's family of any significant changes in condition. However, this protocol was not followed, as evidenced by the lack of documentation and communication regarding the resident's fall and altered mental status. The failure to notify the physician and family of these significant changes placed the resident at risk of not receiving immediate medical attention, which could have led to serious harm.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide a call light system within reach for a resident, identified as Resident #2, who was observed to have significant medical conditions including hemiplegia, hemiparesis, unspecified visual loss, seizures, and dysarthria following a stroke. The resident was also a right leg amputee and had a moderate mental impairment with a BIMS score of 10. The care plan for Resident #2 indicated a risk for falls and included an intervention to ensure the call light was within reach. However, during observations, the call light was found underneath the bed and out of reach, which the resident confirmed, stating he could not see well and was unaware of the call light's location. Interviews with staff, including a CNA, LVN, and the DON, revealed that the responsibility for ensuring call lights are within reach lies with the CNAs, who are expected to make rounds every two hours and check at the beginning and end of their shifts. The Administrator emphasized the importance of following care plans and keeping call lights accessible, especially for residents needing ADL assistance. The facility's call light policy also mandates that call lights be accessible from various locations, including the bed. Despite these guidelines, the failure to ensure the call light was within reach for Resident #2 was identified as neglect by the LVN.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #2, who was at risk for falls and injury due to a seizure disorder. Despite the care plan indicating the need for a fall mat in the resident's room while in bed, the facility did not provide this intervention. This oversight was identified through record reviews and interviews, revealing that the resident had not been offered a fall mat from the time of admission until the survey date. Resident #2, a male with a history of hemiplegia, hemiparesis, unspecified visual loss, seizures, and dysarthria following a stroke, was admitted to the facility with moderate mental impairment. Observations and interviews confirmed that the resident, who also had a right leg amputation above the knee, was not provided with a fall mat as required by his care plan. Interviews with the charge nurse and the Director of Nursing (DON) indicated a lack of awareness and understanding of why the fall mat was not in place, despite the expectation that care plans be followed. The facility's care plan policy mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents' needs, which was not adhered to in this case.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident who required extensive assistance with activities of daily living (ADLs). The resident, a male with a history of type 2 diabetes mellitus, morbid obesity, cerebral infarction, and osteoarthritis, was dependent on staff for personal hygiene due to his medical conditions. Despite being scheduled for bed-baths on Mondays, Wednesdays, and Fridays, the resident reported going up to a week without receiving a bed-bath. He also mentioned that staff sometimes informed him that he would not receive a bath on scheduled days, and he had never refused a bed-bath. Observations and interviews revealed that the resident's room had a strong smell of feces, indicating a lack of proper hygiene care. The resident expressed feeling disrespected by female staff who made fun of his size, which affected his self-esteem. Interviews with staff members highlighted issues with staffing shortages, which contributed to the failure to provide scheduled showers or bed-baths. The facility's shower log confirmed that the resident had not received a shower or bed-bath for six days, and there was no documentation of the resident refusing care. The facility's Director of Nursing (DON) and Administrator acknowledged the issue, with the DON stating that CNAs were responsible for ensuring residents received ADL assistance, including showers and baths. The Administrator emphasized the importance of offering showers every other day and expressed zero tolerance for residents not receiving their scheduled hygiene care. The facility's policies outlined the schedule for showers and the importance of timely responses to residents' needs, but these were not adhered to, resulting in the deficiency.
Failure to Ensure Resident Safety and Care Plan Adherence
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not ensure that a resident, who had a primary diagnosis of hemiplegia and hemiparesis following a cerebrovascular disease, had a call light within reach. This resident, who also had a moderate mental impairment and was at risk for falls due to a seizure disorder, was observed without a call light within reach on multiple occasions. The call light was found underneath the bed, out of the resident's reach, which prevented the resident from communicating with staff when assistance was needed. Additionally, the facility did not provide a fall mat next to the resident's bed as indicated in the resident's care plan. Despite the care plan specifying the need for a fall mat due to the resident's risk for falls and injury, the resident reported never having been offered a fall mat. This oversight was confirmed by staff interviews, where it was revealed that the charge nurse and the Director of Nursing (DON) were unaware of the absence of the fall mat in the resident's room. Interviews with facility staff, including the charge nurse and the DON, highlighted a lack of awareness and adherence to the resident's care plan. The facility's call light policy required that call lights be accessible to residents, yet this was not followed. The Administrator expressed high expectations for care plans to be followed, but the deficiency in ensuring the resident's call light was within reach and the absence of a fall mat indicated a failure to meet these expectations.
Failure to Ensure Proper Catheter Orders and Care
Penalty
Summary
The facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices for three residents who had indwelling urinary catheters without a physician's order. Resident #1, a male with multiple diagnoses including obstructive uropathy and moderate cognitive impairment, had an indwelling catheter without a valid physician's order. His care plan included catheter care every shift, but the physician orders tab did not reflect an order for the catheter itself, only for catheter care and output monitoring. Resident #1 was observed with a catheter bag hung below his wheelchair, and he reported no issues with his catheter or care provided. Resident #2, a male with diagnoses including paraplegia and obstructive uropathy, also had an indwelling catheter without a physician's order. His care plan included catheter care every shift and monitoring of urine characteristics, but the physician orders tab only included an order to record urinary output from the catheter. Resident #2 was observed with a catheter at a local hospital but declined to speak with the surveyor. Similarly, Resident #3, a male with severe cognitive impairment and obstructive uropathy, had an indwelling catheter without a physician's order. His care plan included catheter care every shift and monitoring for signs of a urinary tract infection, but the physician orders tab only included an order for catheter care. The Assistant Director of Nursing (ADON) was unaware that these residents did not have the necessary physician orders for their catheters. The ADON stated that it was the responsibility of the admitting nurse to review admittance orders and notify the physician of the catheter, who would then write the necessary orders. The ADON acknowledged that not having these orders could introduce an infection control issue. The facility's policy on catheter care did not include verbiage regarding a valid rationale for the placement of an indwelling urinary catheter.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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