Duncanville Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duncanville, Texas.
- Location
- 419 S Cockrell Hill Rd, Duncanville, Texas 75116
- CMS Provider Number
- 676178
- Inspections on file
- 77
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Duncanville Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with acute kidney failure, COPD exacerbation, muscle weakness, severe cognitive impairment, and frequent incontinence received incontinent care during which a CNA failed to follow the facility’s infection control and hand hygiene policy. The CNA removed soiled gloves after cleaning urine and a small bowel movement, then donned clean gloves taken from her uniform pocket without performing hand hygiene between glove changes, and proceeded to apply a clean brief. In interviews, the CNA and an RN confirmed that facility policy requires hand hygiene before and after glove use, glove changes with hand hygiene between dirty and clean tasks, and obtaining gloves from room glove boxes rather than carrying them in pockets.
Staff did not ensure that all residents at the same dining table were served meals simultaneously, resulting in two residents having to wait while another ate, which caused discomfort and was acknowledged as inappropriate by staff. Additionally, a resident with quadriplegia repeatedly found her bed unmade until late in the day, despite requests and facility policy requiring beds to be made before lunch. These failures affected residents with significant medical needs and were confirmed through observation and staff interviews.
A medication aide failed to perform hand hygiene between direct contact with multiple residents while serving meals, despite available hand sanitizer and prior education. The residents involved had significant medical conditions and required assistance with daily living. The DON confirmed that staff are required to follow hand hygiene protocols, but no recent in-services had been conducted.
A resident with a colostomy did not receive timely assistance with changing their colostomy bag upon request, resulting in prolonged periods with a full or leaking bag and stained clothing. Staff interviews confirmed that only nurses could change colostomy bags, and delays in response were common, sometimes lasting an entire shift. The DON and administrator acknowledged that such delays could impact resident dignity and care, and the facility's colostomy care policy was not provided during the survey.
A resident with multiple medical and cognitive conditions, who was on hospice care, tied a call light cord around his neck. The incident was not reported to the State Survey Agency within the required timeframe, and no incident report or internal investigation was completed, despite facility policy and regulatory requirements.
A resident with severe cognitive impairment and a full code status was found unresponsive, but the assigned RN failed to initiate CPR or call 911 despite being informed by family and staff of the resident's code status. Another RN eventually began CPR after a delay, and the resident was transported to the hospital by EMS but later expired. The deficiency was due to the RN's failure to follow established protocols and physician orders.
A registered nurse worked without a valid license after it had expired, due to the facility's failure to conduct required monthly license verifications and annual background checks. The issue was discovered through a state board of nursing check, and the responsible HR staff and administrator were unaware of the lapse until after the fact.
Ten dinner trays with leftover food and trash were left in the dining hall overnight and not removed before breakfast, resulting in an unclean environment as residents arrived for their morning meal. A resident expressed concern about clutter and pests, while dietary staff and management acknowledged the oversight and its potential impact on cleanliness and food safety.
Surveyors found that food items in the kitchen were not consistently labeled, dated, or sealed, with moldy produce, improperly covered containers, and a dented can present. Staff interviews revealed uncertainty about cleaning routines and inconsistent adherence to food safety policies, resulting in food storage and handling practices that did not meet professional standards.
A resident with a history of PAD, diabetes, and hypertension, who was cognitively intact, reported that $611.00 was taken from her after a medication aide and the aide's family member became involved in a personal financial transaction following the resident's discharge. The aide shared the resident's contact information with her family member, who then facilitated the withdrawal of funds for an apartment deposit that was never returned. The administrator, when informed, did not act, citing the resident's discharge status, and the facility could not provide a relevant confidentiality policy.
A resident with hemiplegia and a history of stroke reported being physically abused by another resident, an incident witnessed by the DON. Although the DON notified the Administrator (Abuse Coordinator) within an hour, the required report to state authorities was not made within the mandated two-hour window. The Administrator was unable to provide documentation of a timely report, and the facility's policy requiring prompt reporting was not followed.
A resident with unsteadiness on feet experienced multiple falls without injury, but the facility failed to update the care plan with new interventions in a timely manner. Despite the falls, no changes were made to the resident's environment, such as adding floor mats or adjusting bed height. Staff interviews highlighted the importance of updating care plans within 24 to 48 hours after a fall to prevent further incidents.
A LTC facility failed to provide proper pharmaceutical services, resulting in medication administration errors for three residents. An LVN administered medications via a gastrostomy tube against physician orders, crushed medications that should not be crushed, and gave insulin labeled for another resident. An MA failed to administer the correct dosage of liquid Potassium Chloride and did not mix MiraLAX with the correct amount of water. These actions violated medication administration protocols and put residents at risk.
A CNA failed to perform hand hygiene after direct contact with multiple residents during meal service, violating the facility's infection control program. This lapse involved residents with various medical conditions, including cognitive impairments and chronic illnesses. Despite training, the CNA did not sanitize hands between interactions, risking cross-contamination.
A resident with multiple serious health conditions requested to be sent to the hospital during dialysis, but the facility staff did not honor the request, citing the need for corporate approval. Despite stable vital signs, the resident's dissatisfaction and potential risk were noted. Interviews revealed unclear facility policies regarding hospital transport requests.
The facility failed to maintain food safety standards, with unclean equipment, improper food labeling, and inadequate hand hygiene practices observed. Staff did not consistently wash hands or change gloves, risking cross-contamination. Food items lacked proper labeling and were stored past expiration dates, and dented cans were not separated, increasing the risk of food-borne illnesses.
A resident with severe cognitive impairment was found with long, discolored fingernails and scratches on his forehead, indicating a failure in maintaining personal hygiene. Despite requiring extensive assistance with ADLs, the care plan did not reflect any resistance to nail care. Staff interviews confirmed regular showers but noted occasional resistance to nail trimming. The facility lacked documentation of a nail care policy.
A resident with severe cognitive impairment was found with superficial scratches on the forehead, which were not documented or assessed by the facility staff as required by protocol. Despite being informed, an LVN did not evaluate the scratches, and no incident report or 24-hour report notation was made, deviating from the facility's policy and placing the resident at risk.
A resident with multiple health conditions was served cold and improperly cooked food, despite having filed a grievance about meal temperatures. The LVN did not offer to warm the food, and a group of residents confirmed that meals were often served cold. The facility's administrator was aware of the issue but did not ensure it was resolved.
A resident with a documented allergy to milk products did not consistently receive lactose-free milk, leading to discomfort and dissatisfaction. Despite grievances and requests, the dietary staff failed to provide the necessary dietary accommodations, and the issue persisted until the administrator intervened.
A resident with dementia and on anticoagulant therapy had superficial scratches on his forehead that were not documented or assessed by facility staff. Despite being observed by a CNA, the scratches were not recorded in the resident's medical records or reported in the facility's 24-hour report. Interviews revealed that staff did not adhere to the facility's policy for documenting changes in a resident's condition, leading to a deficiency in maintaining accurate clinical records.
A facility failed to ensure proper storage and administration of medications, as an LVN left a medication cart unlocked and preset medications, including a controlled substance, for a resident with quadriplegia and chronic pain. The DON confirmed that carts should be locked when not in sight and medications should not be preset, per facility policy.
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, despite the resident having multiple care needs. Both the DON and the Administrator were unsure why the plan was not completed, which is required by the facility's policy.
The facility failed to ensure that Medication Cart #1 was locked when unattended, posing a risk of unauthorized access to medications. Nurse C left the cart unlocked for three minutes, and both Nurse C and the DON acknowledged the associated risks. Facility policy mandates that all drugs and biologicals be stored in locked compartments accessible only to authorized personnel.
Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program during incontinent care for one resident. The resident was an older male with acute kidney failure, COPD with exacerbation, muscle weakness, severe cognitive impairment (BIMS score 07), and was frequently incontinent of bowel and bladder. During an observation of incontinent care, a CNA entered the resident’s room, washed her hands, donned clean gloves, and assisted the resident from his wheelchair to the bed. She unfastened a urine-soaked brief that also contained a small bowel movement, cleaned the resident’s front area, and then helped him turn to his right side to clean his buttocks. After removing the soiled brief and placing it in a plastic bag, the CNA removed her gloves and then took a clean pair of gloves from her uniform pants pocket. The CNA put on the clean gloves without performing any hand hygiene between glove changes and then applied a clean brief and covered the resident. She removed her gloves, performed hand hygiene, and exited the room. In a subsequent interview, the CNA acknowledged she was required to perform hand hygiene before and after removing the dirty brief, to change gloves with hand hygiene after cleaning the resident and before applying a clean brief, and that she should not carry gloves in her pockets but obtain them from glove boxes in the room. She stated she forgot to bring hand sanitizer and recognized that not following hand hygiene and infection control policy could lead to cross contamination and infection. An RN interview confirmed that staff were expected to perform hand hygiene before and after care, to use hand sanitizer or wash hands when soiled, to change gloves and perform hand hygiene between dirty and clean tasks during incontinent care, and that gloves were supplied in each room and not to be carried in pockets. Review of the facility’s hand hygiene policy showed that hand hygiene is considered the primary means to prevent spread of infection, must be performed before and after applying non-sterile gloves, and that gloves do not replace hand hygiene.
Failure to Uphold Resident Dignity in Meal Service and Room Care
Penalty
Summary
The facility failed to treat several residents with respect and dignity, as required by resident rights policies. Specifically, staff did not ensure that all residents seated at the same dining table were served their meals at the same time. One resident was observed eating lunch while two other residents at the same table waited to be served, with one resident expressing discomfort at having to watch another eat before receiving her own meal. Another resident, who was nonverbal, indicated agreement with this sentiment through gestures. Staff interviews confirmed that the expectation is for all residents at a table to be served simultaneously, but this was not consistently practiced due to the way trays were distributed from the kitchen. Additionally, the facility failed to make up a resident's bed in a timely manner, despite repeated requests from the resident. The resident, who has quadriplegia and no cognitive impairment, reported that her bed was often left unmade until late in the day, sometimes as late as 6:00 p.m. or 8:00 p.m., which interfered with her preferred bedtime and caused her embarrassment when visitors arrived. Observations confirmed that the bed remained unmade well into the afternoon, and staff interviews revealed a lack of consistent follow-through on making beds before lunchtime, as required by facility policy. The residents involved had significant medical conditions, including heart failure, hypertension, diabetes, aphasia, stroke, depression, and quadriplegia. Despite these needs, the facility did not uphold their rights to a dignified environment and timely care. Staff and administration acknowledged awareness of the policies but did not ensure their consistent implementation, resulting in residents feeling their dignity was compromised.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by a medication aide's failure to perform proper hand hygiene while serving meals in the main dining room. Observations revealed that the aide, after washing her hands and adjusting her clothing, did not use hand sanitizer before serving lunch trays to multiple residents. The aide had direct contact with residents, including touching their hands and shoulders, and handled meal trays and utensils without performing hand hygiene between each interaction. Hand sanitizer was available in the dining room, but was not used by the aide during the meal service. Record reviews indicated that the residents involved had significant medical conditions, including heart failure, hypertension, diabetes, atrial fibrillation, and cognitive impairments, requiring varying levels of assistance with activities of daily living. Interviews with the aide confirmed she did not complete hand hygiene after resident contact, despite being educated on the procedure. The Director of Nursing acknowledged that staff are required to perform hand hygiene after resident contact and that supplies were available, but also stated that no in-services on hand hygiene had been conducted since her recent arrival at the facility. Facility policies required regular staff education and adherence to hand hygiene protocols to prevent the spread of infections.
Failure to Provide Timely Colostomy Care Upon Resident Request
Penalty
Summary
A deficiency was identified when a resident who required colostomy care did not receive timely assistance with changing their colostomy bag upon request. The resident, who had a history of intestinal obstruction, dysphagia, cognitive communication deficit, and gastrostomy status, reported to a state surveyor that he wanted his colostomy bag changed because it had not been emptied since the previous night and was starting to lift, raising concerns about potential leakage. The resident used the call light, and a facility aide informed the nurse of the request. However, the bag was not changed promptly, and the resident stated that the bag had leaked on his clothes before, though he could not recall the exact timing. Further evidence was provided by a complainant who observed the resident in bed with a leaking colostomy bag that had stained his clothing. The complainant witnessed an aide inform the nurse, but it took over two hours for the nurse to respond and change the bag, after which the aide cleaned the resident. A photograph submitted by the complainant showed visible stains on the resident's clothing. Interviews with CNAs confirmed that only nurses were permitted to change colostomy bags and that there were repeated delays in fulfilling resident requests, sometimes lasting an entire shift. CNAs expressed concerns that such delays could lead to leaks, skin irritation, and dignity issues for the resident. A nurse confirmed that the resident had requested a bag change but stated she had only burped the bag and planned to change it after the resident ate lunch, claiming the bag was not full and there was no immediate risk. Both the DON and the administrator stated that residents have the right to have their colostomy bags changed upon request and acknowledged that delays could result in dignity issues and potential harm. The facility's policy on colostomy care was requested but not provided before the survey exit.
Failure to Timely Report and Investigate Alleged Abuse/Neglect Incident
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident involving a male resident with chronic diastolic heart failure, severe intellectual disabilities, and cognitive communication deficit, who was admitted to hospice, was not reported. The resident was found to have tied a call light cord around his neck, an event that was not communicated to the State Survey Agency as required by regulation. Interviews with facility staff, including the ADON, NP, previous DON, and the administrator, revealed that the resident had not previously expressed suicidal ideations or intentions to harm himself, and assessments did not indicate such risks. The incident occurred while hospice staff were still present in the building, and the resident was subsequently placed on one-to-one supervision and sent for psychological evaluation after expressing a desire to harm himself. However, there was no documentation of an incident report or an internal investigation being completed for this event. A review of facility records and policies confirmed that the incident was not reported in the TULIP system, and the facility's Abuse Prohibition Policy required notification of such events to proper authorities according to state and federal regulations. The administrator acknowledged that not completing an incident report and investigation could have placed residents at harm if signs were not recognized and acted upon in a timely manner.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with severe cognitive impairment, multiple diagnoses including dementia, and a terminal prognosis related to Alzheimer's disease, was admitted as a hospice patient. Her medical records, care plan, and physician orders indicated she was a full code, meaning she should receive resuscitation efforts in the event of cardiac or respiratory arrest. At the time of the incident, the resident's advance directive status was not updated to DNR, as the necessary documentation had not been signed by the responsible party or physician. On the day of the incident, the resident was found unresponsive by family members, who immediately notified the assigned RN. Despite being informed multiple times by family and other staff that the resident was a full code and required CPR, the RN failed to initiate life-saving measures. The RN did not check the resident's code status or follow the physician's orders and facility policy to begin CPR and call 911. Other staff, including a CNA and another RN, became involved after being alerted to the situation. The second RN ultimately initiated CPR, but only after a significant delay and after being verbally notified by the CNA. There was no announcement of a code blue over the PA system, and the initial RN left the room before EMS arrived, failing to communicate with emergency personnel about the resident's condition and care provided. Interviews with staff and review of documentation confirmed that the RN responsible did not follow established protocols for determining code status and initiating emergency response. The failure to provide timely CPR and activate emergency procedures was corroborated by multiple witnesses, including family members, other nursing staff, and hospice personnel. The resident was eventually transported to the hospital by EMS, but later expired. The deficiency was identified as a result of the RN's inaction and lack of adherence to the resident's documented wishes and medical orders.
Failure to Ensure Nursing Staff Maintained Current Licensure
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) maintained a current and valid nursing license in accordance with state laws and regulations. Record review and interviews revealed that the RN's license had expired, and the facility did not verify or identify the lapse in licensure. The Human Resources (HR) staff member responsible for conducting monthly license verifications and annual background checks was unaware of the expired license and had not completed the required checks for the RN during the current year. The RN continued to work as a full-time charge nurse and later as PRN without a valid license until termination. The Administrator (ADM) was not aware of the RN's expired license and believed all nursing licenses were current. The ADM stated that if he had known about the expired license, the RN would have been suspended until renewal. The facility did not provide a policy for review regarding license verification. The deficiency was confirmed through the state board of nursing's online verification, which showed the RN's license as expired. No information was provided regarding any residents directly affected by this deficiency.
Failure to Remove Used Dinner Trays Results in Unclean Dining Hall Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the dining hall by not removing ten dinner trays with food and trash from the previous evening before breakfast the next morning. During an observation, these trays were found on tables and a cart in the dining hall while approximately eight residents were present awaiting breakfast. A resident reported that trays from the previous night were sometimes left out and expressed concern about clutter and the potential for pests. Interviews with dietary staff and the interim dietary manager revealed that evening staff were responsible for returning trays to the kitchen, but sometimes caregivers brought trays back to the dining hall after kitchen staff had left. In such cases, morning kitchen staff were expected to clear the trays before breakfast service. The interim dietary manager and the administrator acknowledged that leaving trays out could result in not having enough trays for breakfast, risk of cross contamination, pest attraction, and the possibility of residents consuming spoiled or contaminated food. Review of the facility's policy confirmed residents' rights to a safe and appropriate living environment.
Failure to Properly Store, Label, and Seal Food in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food. Specifically, food items in the refrigerator, freezer, and pantry were found to be improperly labeled, undated, and unsealed. Moldy sweet potatoes and cucumbers, an unlabeled and loosely covered container of mixed fruit, chopped chicken in an unsealed bag, and other improperly stored items were noted. Additionally, a dented can of black eye peas was found in dry storage, and a single-serve cup of orange sherbet in the freezer was not properly sealed. Staff interviews confirmed that all dietary staff were responsible for labeling, dating, sealing, and checking for spoiled foods, but there was uncertainty about the frequency of cleaning and removal of expired or spoiled items. The facility's policy required all food items to be labeled, dated, and properly sealed, with dented cans and expired foods to be removed from storage. However, observations and staff interviews revealed these procedures were not consistently followed. The Interim Dietary Manager, who was only present part-time, was unsure of the facility's routine practices, and staff acknowledged the risks of contamination and cross-contamination due to these lapses. The facility's practices were not in accordance with professional standards or the FDA Food Code requirements for food safety and date marking.
Failure to Protect Resident from Exploitation and Misappropriation of Property
Penalty
Summary
A deficiency occurred when a resident reported that $611.00 was taken from her following interactions with a medication aide (MA) and the MA's family member. The resident, who had diagnoses including peripheral arterial disease, type 2 diabetes mellitus without complications, and essential hypertension, was cognitively intact at the time of the incident. While residing at the facility, the resident befriended the MA, who obtained her personal phone number. After the resident was discharged, the MA contacted her regarding renting an apartment, and the MA's family member drove the resident to the bank to withdraw $611.00 for an apartment deposit. The resident provided the money and received a signed note from the MA's family member acknowledging the deposit. Subsequently, the apartment arrangement fell through, and the resident was unable to recover her funds despite repeated attempts to contact the MA. The administrator (ADM) was made aware of the incident but did not take further action, stating that the event occurred after the resident's discharge and did not believe the facility was responsible. The MA admitted to sharing the resident's phone number with her family member and acknowledged the relationship between her family member and the resident. The facility was unable to provide a policy related to the confidentiality of resident information or employee violations when requested. The report documents that the facility failed to protect the resident from exploitation and did not ensure the resident's right to be free from misappropriation of property.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents, as required by Texas law and facility policy. Specifically, a resident with hemiplegia and a history of stroke, who was cognitively intact, reported being physically abused by another resident. The incident, witnessed by the DON, involved one resident grabbing another by the jacket around her shoulder. The DON reported the incident to the Administrator, who serves as the Abuse Coordinator, within an hour. However, the Administrator did not report the allegation to the state agency within the required two-hour timeframe. Instead, the initial report was delayed, and there was confusion regarding the date of the incident and the method of reporting, with the Administrator unable to provide documentation of a timely report. Record review showed that the facility's notification to the state agency was not sent until two days after the incident, and the provider investigation report was also delayed. Interviews with staff revealed a lack of clarity regarding the reporting timeframe, with the DON believing the requirement was 24 hours rather than two. The facility's policy clearly states that allegations of abuse must be reported within two hours, but this protocol was not followed in this case, resulting in a deficiency for failure to timely report suspected abuse.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, specifically following incidents of falls. The resident, a male with a diagnosis of unsteadiness on feet, experienced multiple falls without injury during his stay. Despite these incidents, the care plan was not updated with new interventions until over a month later, which could potentially place residents at risk of not addressing individualized needs and services. The resident had two falls on specific dates, and no interventions were entered into his care plan following these events. Interviews with the resident revealed that he did not notice any changes in his room, such as the addition of floor mats or adjustments to the bed height, after his falls. The care plan was eventually updated, but not in a timely manner, as it was revised only after the third fall occurred. Interviews with facility staff, including CNAs, the ADON, and the Regional RN, highlighted the importance of updating care plans promptly to prevent further incidents. The staff indicated that care plans should be updated within 24 to 48 hours after a fall to ensure that appropriate interventions are in place. The facility's policy also emphasized the need for ongoing assessments and revisions of care plans as residents' conditions change.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication administration errors. A Licensed Vocational Nurse (LVN) administered medications to a resident via a gastrostomy tube without following physician orders, which specified oral administration. The LVN also failed to check the placement of the gastrostomy tube or check for residuals before administering the medications. Additionally, the LVN crushed medications that should not have been crushed, including Potassium ER and pantoprazole DR, potentially altering their effectiveness and causing harm. Another resident did not receive the correct dosage of liquid Potassium Chloride due to a medication spill that was not properly addressed by a Medication Aide (MA). The MA also failed to mix MiraLAX powder with the correct amount of water as per the physician's orders, leading to uncertainty about the actual dosage administered. These actions demonstrate a lack of adherence to medication administration protocols, putting the resident at risk of not receiving the intended therapeutic benefits. Furthermore, the LVN administered insulin labeled for a different resident to a third resident, which is a direct violation of medication administration policies. The Director of Nursing (DON) acknowledged that insulin should only be given to the patient it was prescribed for, and the Pharmacist Consultant highlighted the potential gastrointestinal harm from crushing certain medications. Despite these acknowledgments, the facility's staff failed to follow established procedures, resulting in multiple medication errors.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with four residents while serving meals. This lapse in protocol was observed during meal service on Hall 300, where CNA A interacted with residents without using gloves or sanitizing hands between each resident interaction. The failure to adhere to hand hygiene practices could lead to cross-contamination and the spread of infections among residents. Resident #1, a male with moderate cognitive impairment and diagnoses including anemia, hypertension, and heart failure, required assistance with activities of daily living. Resident #2, a female with severe cognitive impairment and diagnoses of diabetes, schizo-affective schizophrenia, and hypertension, also required staff assistance. Resident #3, a female with hypertension, malnutrition, and anemia, was cognitively intact but needed assistance with daily activities. Resident #4, a male with severe cognitive impairment, dementia, and muscle wasting, required staff assistance as well. CNA A's failure to perform hand hygiene after contact with these residents was a direct violation of the facility's infection control policies. During an interview, CNA A admitted to not completing hand hygiene due to being nervous and wanting to serve meals quickly to prevent them from getting cold. The interim DON confirmed that all staff were trained to perform hand hygiene before and after resident contact, and that failure to do so could spread germs. The facility's policy emphasized hand hygiene as the primary means to prevent infection spread, requiring staff to sanitize hands between each tray service. Despite receiving training, CNA A did not adhere to these protocols, leading to the identified deficiency.
Failure to Honor Resident's Request for Hospital Transport
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's choices. A resident, who was moderately impaired and his own responsible party, requested to be sent to the hospital during a dialysis session because he felt unwell. Despite his request, the facility staff did not send him to the hospital, citing the need to contact the nurse practitioner and corporate office for approval, which was not obtained. The resident's medical history included serious conditions such as Hypertensive Heart and Kidney Disease with Heart Failure, End Stage Renal Disease, and Type 2 Diabetes, among others. On the day of the incident, the resident expressed feeling sick and requested hospital transport, but the weekend supervisor instructed the LPN to wait for corporate approval. The LPN attempted to contact the nurse practitioner and the resident's family, who also advised waiting. Despite the resident's stable vital signs, his request to go to the hospital was not honored, leading to dissatisfaction and potential risk. Interviews with facility staff revealed a lack of clarity in the facility's policy regarding sending residents to the hospital upon request. The DON stated that residents should be sent to the hospital if requested, without waiting for a doctor's approval, to avoid violating resident rights. However, the Executive Director noted that the facility's policy was vague, and the staff attempted to handle the situation in-house first. The ADON later stated she did not recall being asked about the situation, and the facility's policy on calling 911 was reviewed, highlighting the need for clearer guidelines.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. The ice machine chute guard was found to be unclean, with a light pink stain across its length. Additionally, the handwashing sink had smudges and food particles, and the garbage receptacle contained items other than paper towels. The facility also failed to maintain proper labeling and storage of food items in refrigerators, freezers, and dry storage. Many items lacked labels indicating the item description, received by date, opened date, and consume by or expiration dates. Some items were stored past their expiration dates, and others were left open to air, increasing the risk of contamination. The facility's staff did not consistently practice proper hand hygiene and use of personal protective equipment (PPE). Observations revealed that staff members, including cooks and dietary aides, frequently handled food and kitchen equipment without washing their hands or changing gloves after touching potentially contaminated surfaces. This included instances where staff members touched their masks, sneezed into their hands, and then continued food preparation without proper sanitation measures. Such practices could lead to cross-contamination and pose a risk of food-borne illnesses to residents. Furthermore, the facility did not have a separate area for storing dented cans, which were found mixed with undented cans. This oversight could lead to the use of compromised food products. The facility's Nutrition Services Food Storage Policy, revised in December 2020, was not followed, as evidenced by the lack of proper labeling and storage practices. The U.S. FDA Food Code 2022 guidelines were also not adhered to, as food items were not consistently labeled with the common name, preparation date, or expiration date, and were not stored according to the first in/first out basis. These deficiencies in food safety practices could place residents at risk for food-borne illnesses and cross-contamination.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #19, a male with severe cognitive impairment due to dementia and anxiety, was observed with long, discolored fingernails and superficial scratches on his forehead. The resident required extensive assistance with ADLs and was not resistive to nail care according to his care plan. However, his nails were not trimmed or cleaned, which could have contributed to the scratches on his forehead. Interviews with staff revealed that the resident received regular showers and was non-combative, but sometimes did not like to have his nails trimmed. Despite this, the care plan did not reflect any resistance to nail care. The facility's administration acknowledged the importance of attending to residents' ADLs, including nail care, to prevent potential dignity issues and infection risks. However, there was no documentation of a nail care policy provided during the review.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency was identified when a CNA did not note superficial scratches on the resident's forehead during a morning observation. The resident, who has severe cognitive impairment and requires extensive assistance with activities of daily living, was observed with scratches that had dried blood, yet these were not documented or reported as required by the facility's protocol. Later in the day, an LVN was informed about the scratches but did not assess them, citing time constraints due to end-of-shift responsibilities. Despite being notified, the LVN did not document the scratches in the resident's progress notes or the facility's 24-hour report, which is used to communicate changes in residents' conditions. The lack of documentation and assessment of the scratches was a deviation from the facility's policy, which mandates immediate assessment and documentation of any new skin conditions. Interviews with various staff members, including CNAs and RNs, revealed that the facility's protocol requires any change in a resident's skin condition to be reported and documented. However, in this case, the protocol was not followed, as evidenced by the absence of any incident report or notation in the 24-hour report. This oversight placed the resident at risk for potential complications, as the scratches were not promptly assessed or treated according to the facility's standards.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food and drink were served at a palatable, attractive, and appetizing temperature for a resident reviewed for food and nutrition. The resident, a cognitively intact female with multiple diagnoses including stroke, seizures, depression, diabetes, and bipolar disorder, was served cold eggs and cream of wheat for breakfast, which she attempted to eat but found unappetizing. Additionally, during lunch, she was served a half-cooked baked potato, which she could not eat. The resident had previously filed a grievance about cold food being served at meals. Interviews and observations revealed that the LVN who served the breakfast did not offer to warm the food, assuming the resident would not eat well anyway. A group meeting with ten residents confirmed that food was often served cold and was not as tasty as before. The facility's administrator acknowledged receiving grievances about cold food and had discussed the issue with the dietary manager, but did not follow up to ensure the problem was resolved. The facility's policy on resident rights emphasizes the importance of providing adequate and appropriate care and services, which was not adhered to in this instance.
Failure to Provide Lactose-Free Milk for Resident with Allergy
Penalty
Summary
The facility failed to provide food that accommodates the allergies and preferences of a resident, specifically lactose-free milk, despite the resident's documented allergy to milk products. The resident, who is cognitively intact and requires assistance with daily activities, reported ongoing issues with receiving lactose-free milk, which was not consistently available in the facility. The resident experienced discomfort from consuming regular milk due to the lack of lactose-free options, despite having raised grievances about the issue. Observations and interviews revealed that the dietary staff did not consistently have lactose-free milk available, and the dietary manager did not respond to the resident's requests. The resident had previously informed the administrator about the issue, but no effective action was taken to ensure the availability of lactose-free milk. The dietary aide confirmed that lactose-free milk was not always available, and it was only obtained when the administrator intervened. The facility's failure to provide lactose-free milk as per the resident's dietary needs and preferences was documented in a grievance filed by the resident. The grievance was acknowledged, but the corrective action to provide the product was not effectively implemented, leading to continued dissatisfaction and discomfort for the resident.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident #19, who had superficial scratches on his forehead. On the morning of July 8, a CNA observed the scratches but did not document them in the resident's medical records. Later that day, an LVN was informed of the scratches but did not assess them, as she was occupied with her end-of-shift report. The lack of documentation and assessment of the scratches was a deviation from the facility's protocol for reporting changes in a resident's condition. Resident #19, a male with dementia and anxiety, was noted to have severe cognitive impairment and required extensive assistance with activities of daily living. His care plan included daily skin inspections due to his anticoagulant therapy. Despite these requirements, the scratches on his forehead were not documented in his progress notes, incident reports, or the 24-hour report, which are essential for ensuring all nursing staff are aware of changes in a resident's condition. Interviews with facility staff revealed a lack of adherence to the facility's policy for reporting and documenting skin conditions. The CNA who gave Resident #19 a shower did not note any scratches, and the LVN did not have time to assess the scratches. The Director of Nursing confirmed that any change in a resident's condition should be reported and documented, highlighting a failure in the facility's processes to ensure resident safety and proper care.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles, specifically in locked compartments, and that only authorized personnel had access to the keys. This deficiency was observed when LVN A left a medication cart unlocked outside a resident's room, which was closed at the time. Additionally, LVN A was seen preparing medications, including a controlled substance, and placing them in a medication cup, which was then locked in the cart for an extended period before administration. This practice of presetting medications is against the facility's policy and could lead to medication misuse and diversion. Resident #28, who was alert and oriented with a BIMs score of 12, was the intended recipient of the preset medications. The resident had a history of quadriplegia, anxiety, constipation, and chronic pain, requiring multiple medications for management. The Director of Nursing (DON) confirmed that medication carts should always be locked when not in direct sight and that medications should not be preset, especially narcotics. The facility's policy on administering medications, revised in April 2019, mandates that medication carts be kept closed and locked when out of sight of the nurse or aide.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #1 within 48 hours of admission. The resident, a [AGE] year-old male, was admitted on an unspecified date and had multiple care needs, including dependency for eating, oral hygiene, toileting hygiene, showering/bathing, dressing, personal hygiene, mobility, sitting/standing, transferring, and required a wheelchair. Additionally, the resident had a g-tube, was cognitively impaired, always incontinent, had an external catheter, required tube feeding, and needed physical, occupational, and speech therapy. Despite these needs, the baseline care plan was not completed within the required timeframe, as confirmed by the Director of Nursing (DON) and the Administrator during interviews on 02/07/24. The DON and the Administrator both expressed uncertainty as to why the baseline care plan was not completed within 48 hours. The Administrator noted that the baseline care plan is a simple document that mainly requires checking yes or no on various items. The facility's policy, dated 10/23/23, mandates that a baseline plan of care to meet the resident's immediate health and safety needs be developed within 48 hours of admission. The failure to complete this plan within the specified timeframe resulted in a lack of documentation on what the resident needed, potentially affecting the quality of care provided to newly admitted residents.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that Medication Cart #1 was locked when unattended, which could place residents at risk of unauthorized access to medications and potential harm or drug diversion. During an observation and interview, it was noted that Medication Cart #1 was left unlocked and unattended in the 100 hall between specific rooms for an additional three minutes before Nurse C returned. Nurse C admitted she was unaware that she had left the cart unlocked and acknowledged the risk involved. The Director of Nursing (DON) also confirmed the risk of leaving the medication cart unlocked. A review of the facility's policy on the storage of medications revealed that all drugs and biologicals should be stored in locked compartments, accessible only to authorized personnel.
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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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