Edgemere Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 10880 Edgemere Blvd, El Paso, Texas 79935
- CMS Provider Number
- 675831
- Inspections on file
- 37
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Edgemere Estates during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of aggression entered another resident's room and physically assaulted her after being told to leave. The aggressive resident had a pattern of similar behaviors, but care plans and documentation did not reflect the need for close supervision or non-pharmacological interventions. Staff interviews revealed inconsistent awareness of behavioral interventions, and facility records lacked adequate documentation of behaviors and interventions, contributing to the incident of resident-to-resident abuse.
A resident with severe dementia and multiple behavioral health diagnoses repeatedly refused care and exhibited aggressive behaviors, including entering other residents' rooms and physical aggression. The facility did not adequately address the resident's routines, preferences, or triggers in the care plan, nor did it document or implement effective non-pharmacological interventions. Documentation of behaviors and interventions was lacking, and staff training on dementia care could not be verified, resulting in insufficient management of the resident's dementia-related behaviors.
A resident with severe cognitive impairment and behavioral issues was prescribed multiple psychotropic medications, but the facility failed to document targeted behavior monitoring and non-pharmacological interventions as required. The Treatment Administration Record only showed side effect monitoring for antidepressants, lacking details on specific behaviors or interventions, despite clear orders and policy requirements.
Four staff members, including an LVN, two CNAs, and the Activities Director, did not have documentation of the required annual in-service training for Dementia and Behavior Management due to a change of ownership and loss of previous training records. Interviews revealed uncertainty among staff about their training status, and the facility could not verify compliance with its own dementia care training policy.
Sharps and blood-stained alcohol prep pads were found left in the drop slots of sharps containers in two rooms, rather than being fully disposed of inside the containers. The affected residents had dementia and cognitive impairments. Staff interviews confirmed that all hazardous items should be completely placed inside sharps containers, but this was not done, leaving the items accessible.
Surveyors found that frozen vegetables, cookie dough, and sausage patties were stored in unsealed bags and open boxes, and kitchen equipment such as the ice machine and deep fryer were not kept clean. Staff interviews confirmed that these practices did not meet facility policies for food safety and sanitation, resulting in unsanitary conditions and improper food storage.
Three resident rooms were found with dirty floors, stained carpets, food debris, and a blood-contaminated alcohol pad left on the floor. Residents with significant medical and cognitive needs reported delays in cleaning, and staff interviews confirmed that these conditions were unacceptable and not in line with facility policy.
Two residents with severe cognitive impairment and high fall risk were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. Staff interviews confirmed responsibility for ensuring call light accessibility, but observations showed lapses in practice.
Dried drippings were observed on bottles of Lactulose Solution and ProHeal Liquid Protein in a medication cart, despite staff being responsible for keeping medication carts and bottles clean and organized. Interviews with nursing staff and supervisors confirmed that daily cleaning and monitoring were expected, but the presence of residue indicated these procedures were not consistently followed.
The facility failed to provide consistent wound care for three residents, leading to a deficiency. A resident with a history of osteomyelitis and myocardial infarction missed multiple wound care sessions for an arterial wound. Another resident with atherosclerosis and hypertension did not receive consistent care for a pressure wound, and a third resident with diabetes and traumatic amputation had lapses in care for a dehiscence wound. Staff interviews revealed systemic issues with weekend wound care, and the Wound Care Doctor was not informed of missed treatments.
A resident with a stage 3 pressure ulcer did not receive necessary wound care on two consecutive days due to systemic issues with weekend staffing. Despite a care plan in place, the facility failed to ensure wound care was performed, as confirmed by staff interviews and lack of documentation. The Treatment Nurse's efforts to address the issue were ineffective, and the Wound Care Doctor was not informed of the lapses.
A facility failed to create a baseline care plan within 48 hours for a newly admitted resident with Type 2 Diabetes Mellitus and a stage 3 pressure ulcer. The absence of this plan, which should have been developed by the admitting nurse, was identified during a record review. Interviews with the ADON and Interim DON confirmed the oversight, which could impact the resident's care.
A resident with Type 2 Diabetes Mellitus and a stage 3 pressure ulcer left the facility against medical advice (AMA) due to inadequate wound care, incontinence care, and medication administration. The facility failed to communicate effectively among staff and did not ensure a safe discharge process. The Social Worker did not confirm the resident's safe arrival at home, and Adult Protective Services (APS) was not contacted in a timely manner, despite concerns about the safety of the resident's home environment.
A resident did not receive prescribed medications for infection and prophylaxis over a weekend due to unavailability and lack of proper communication among staff. The facility's staff resorted to borrowing medications from other residents, which is against policy and state law. This deficiency highlights a failure in the facility's medication management system.
A resident with Type 2 Diabetes Mellitus and a pressure ulcer required substantial assistance for toileting hygiene, but the facility failed to document incontinence care. The resident's family member reported providing this care themselves, and staff interviews revealed a lack of communication and documentation. The facility did not have a baseline or comprehensive care plan for the resident, and there was no record of educating the family on incontinence care.
The facility failed to include oxygen therapy in the care plans of three residents with COPD and respiratory issues, despite medical orders and observations confirming their need for continuous oxygen. This oversight, acknowledged by the ADON and MDS Coordinator, was attributed to staffing changes and transitions in electronic health records, potentially risking the residents' care.
A resident with severe cognitive impairment and physical disabilities was involved in a mechanical lift transfer where a CNA failed to secure the brakes, causing slight movement of the lift. Although the transfer was completed without incident, this oversight could have placed the resident at risk for falls or injury. Staff interviews and facility policy confirmed the importance of securing brakes during transfers.
The facility failed to update care plans for two residents regarding their transfer needs. One resident required a mechanical lift transfer, which was not reflected in the care plan, while another resident's care plan inaccurately indicated the need for a Hoyer lift despite using a 2-person assist transfer. This oversight was due to a lack of monitoring and review, posing a risk of not providing necessary care.
A facility failed to suspend a CNA after an abuse allegation involving a cognitively impaired resident during a toileting transfer. The resident's RP reported the incident, but the CNA continued to work despite the facility's policy requiring suspension during investigations. The DON acknowledged the oversight, and the new administrator confirmed the policy should have been followed.
A resident with severe cognitive impairment and mobility issues was transferred using a mechanical lift without proper brake application, contrary to facility protocol. The Lead CNA admitted to forgetting to apply the brakes, posing a risk of falls or injuries. Interviews confirmed that CNAs were trained to apply brakes during transfers, but the facility's documentation lacked specific guidance on brake usage.
Two residents were injured during transport from a dialysis visit due to the Maintenance Director's failure to secure them with seatbelts. Despite being trained, the Director did not use the required safety measures, resulting in falls and injuries for both residents. The facility's policy mandates the use of safety belts, which was not followed in this instance.
The facility failed to post oxygen signs outside the rooms of four residents receiving oxygen therapy, potentially placing visitors and staff at risk. Despite the facility's policy requiring such signage, observations revealed the absence of these signs. Interviews with staff confirmed the oversight, with the responsibility for posting signs assigned to the charge nurse.
A resident with functional quadriplegia and moderate cognitive impairment was found unable to reach her call light, which was placed over an oxygen concentrator, out of her reach. An LVN confirmed the call button should be accessible, and the DON emphasized staff responsibility to ensure this during rounds. The facility's policy requires call lights to be within easy reach for residents in bed.
A facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission. The resident, admitted with multiple diagnoses including Alzheimer's and heart failure, was identified as a high fall risk, but this was not addressed in the delayed care plan. The delay was due to the MDS Coordinator being off during the weekend when the resident was admitted.
A resident with a full code status was found unresponsive, and the RN on duty failed to initiate CPR immediately due to a lack of knowledge about the proper procedures. This delay in providing life-saving measures was confirmed through staff interviews and record reviews, revealing significant gaps in staff training and emergency response protocols.
A facility failed to provide basic life support, including CPR, to a resident found unresponsive, resulting in the resident's wishes to be resuscitated not being honored. The RN on duty did not know how to respond and did not initiate CPR immediately, leading to a significant delay in emergency response. The facility had not conducted any training on emergency procedures, contributing to the failure.
A therapy staff member at the facility made inappropriate comments and gestures towards a resident, including joking about putting tape on her mouth, which left the resident feeling embarrassed and reluctant to engage in therapy. The incident was reported by the resident and her family member, highlighting a failure to ensure a dignified and respectful environment during therapy sessions.
A resident fell to the floor when a mechanical lift (Hoyer) sling strap tore during a transfer, despite staff having received training to check the slings for wear and tear. The resident experienced pain and bruising, and x-rays revealed no fractures. The facility's policy on routine checks and maintenance of lift equipment was not adequately followed.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment. Observations revealed worn-off paint on handrails, dusty and stained floors, and a water-stained ceiling in storage rooms. The Maintenance Supervisor and Administrator confirmed these issues, which were not reported or addressed according to the facility's cleaning policies.
The facility failed to post contact information for the Long Term Care Ombudsman program in a manner accessible to wheelchair-bound residents. During a group meeting, residents in wheelchairs reported not knowing where to find the Ombudsman information. The Administrator acknowledged that the information was posted too high for these residents to see.
The facility failed to ensure that residents could easily access the most recent survey results. Observations and interviews revealed that the survey binder was located in a restricted lobby area, requiring staff assistance to access. The Administrator was unaware of this issue, and the facility's policy did not address the accessibility of survey results.
The facility failed to notify a resident's physician about the resident's ongoing behavior of removing Prevalon boots, which were ordered for pressure ulcer healing. Despite multiple observations of the resident without the boots, staff did not consistently document or report this behavior, nor was it included in the care plan, placing the resident at risk of delayed treatment.
The facility failed to promptly resolve grievances for two residents, including complaints about verbal aggression and room changes without written notice. The Social Worker and Administrator acknowledged that grievances should have been completed but were not.
A resident alleged that the Administrator forcefully removed her from her room and slapped her hand when she resisted. Despite the resident's clear and consistent allegations, the facility did not report the incident to the State Office as required by their abuse policy. Interviews with staff revealed a lack of clarity and action regarding the reporting process when the alleged perpetrator is the abuse coordinator.
A resident alleged that the Administrator forcefully removed her from her room and slapped her hand. Despite the resident's consistent reports, the facility failed to report the incident to the State Office or conduct a thorough investigation. The Administrator, who was also the abuse coordinator, did not suspend himself pending investigation, citing the presence of witnesses as a reason.
A facility failed to ensure accurate documentation of a resident's CPAP machine use, leading to inconsistencies in the resident's MDS and care plan. Despite physician orders requiring documentation of compliance, the resident's refusal to use the CPAP machine was not consistently recorded, and staff interviews revealed a lack of awareness and proper documentation practices.
A resident with unstageable pressure ulcers was not consistently wearing Prevalon boots as ordered by the physician. Staff observed the resident without the boots multiple times, and behaviors leading to the removal of the boots were not documented or reported consistently.
A resident with COPD and a sleep disorder was not consistently assisted with her CPAP machine as per physician's orders. The facility failed to document non-compliance and assist the resident in using the CPAP machine, leading to significant gaps in usage and potential health risks.
The facility failed to provide accurate pharmaceutical services and proper medication administration for three medication carts and four residents. Issues included lack of physician's orders for G-Tube flush, improper administration of medications, and failure to follow controlled substances procedures. Liquid medications were also improperly stored.
The facility failed to ensure that irregularities identified by reviews of residents' drug regimens by a licensed pharmacist were reported and acted upon. Specifically, the consulting pharmacist did not act on recommendations to administer medications according to manufacturer specifications for two residents, placing them at risk of adverse drug effects.
The facility failed to ensure that residents who had not previously used psychotropic drugs were not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Three residents were prescribed antipsychotic medications without appropriate indications, and the facility's DON and MDS Nurse were not familiar with the risks and appropriate use of these medications.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed issues with dried drippings, white residual, grease build-up, and improper sealing of food containers. The ice machine had white calcium build-up and rust, and puree foods were prepared in unsanitary conditions. Environmental checks revealed rusted vent covers, dark yellow substances on walls, and chipped paint on the ceiling.
The facility failed to properly dispose of garbage and refuse, leaving one dumpster lid uncovered and another side door open, exposing the trash. The Maintenance Director confirmed that dumpsters should always be covered to prevent insect and rodent access, as per the facility's policy.
The facility failed to maintain complete and accurate clinical records for three residents, leading to deficiencies in their care. One resident did not receive appropriate nutrition due to an unaddressed diet order, another's abuse allegation was not documented, and a third's non-compliance with a CPAP machine was not recorded.
The facility failed to maintain a QAPI committee with the required members, as the Medical Director and Infection Preventionist were frequently absent from meetings. This lack of attendance could lead to unidentified quality deficiencies and inadequate action plans.
The facility failed to maintain safe operating conditions for a Hoyer lift and an ice machine. A resident fell due to a torn Hoyer sling strap, and the ice machine had significant calcium build-up, rust, and water leakage for several months, posing risks to resident safety and health.
The facility failed to follow internal abuse policy, report allegations of abuse to the State Office, and conduct a thorough investigation after a resident alleged that the Administrator had slapped her hand during a room transfer. The Administrator did not report the incident or suspend himself pending investigation, citing the presence of witnesses. This failure placed all residents at risk of continued abuse.
The facility failed to maintain an infection prevention and control program, leading to deficiencies such as improper storage of contaminated equipment, reusable water containers, and supply boxes. Observations revealed issues like a hole in a clean linen cart cover, open linen hampers, and equipment stored in hallways and storage rooms without proper disinfection. Interviews with staff confirmed these practices were not in line with the facility's infection control policies.
A resident with a history of conflicts and diagnoses of anxiety, dementia, and depressive disorders was moved to a different room without receiving the required written notice. The facility's administrator decided to move the resident due to complaints of verbal aggression but did not provide the mandated five-day written notice, leading to dissatisfaction from the resident and her family.
A facility failed to ensure a resident's suprapubic catheter was properly secured, leading to potential pain and trauma. Despite protocols requiring the catheter to be secured and checked every shift, staff did not consistently follow these guidelines, and there was a lack of communication and follow-up when issues were identified.
Failure to Protect Resident from Abuse Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident with a known history of aggression and severe cognitive impairment. One resident, who had vascular dementia, impulse disorder, and was severely cognitively impaired, frequently propelled his wheelchair throughout the facility, entered other residents' rooms, and exhibited both verbal and physical aggression toward staff and other residents. On the date of the incident, this resident entered another resident's room, was told to leave, and responded by punching the resident in the arm and attempting to kick her. The aggressor was removed immediately, and the victim was assessed and found to have swelling but no visible injury. Multiple interviews and record reviews revealed that the aggressive resident had a documented history of similar behaviors, including entering other residents' rooms, pushing residents, and being physically and verbally aggressive during care and in the dining room. Staff and leadership acknowledged that the resident required close supervision and redirection, but documentation of these behaviors and interventions was inconsistent or lacking. The care plans for the aggressive resident were not updated to reflect the need for close supervision, did not include non-pharmacological interventions, and failed to document triggers or strategies to prevent recurrence of aggressive behavior. Staff interviews indicated a lack of awareness or familiarity with care plan interventions, and there was no clear communication or documentation of how care plan changes were shared with staff. Additionally, the facility's documentation practices were deficient. Treatment Administration Records (TARs) and care plans did not consistently record the resident's aggressive behaviors, non-pharmacological interventions, or the need for close supervision and redirection. There was also a lack of documentation regarding the identification and monitoring of behavioral triggers. Staff training records on dementia and behavior management were incomplete due to a recent change of ownership, and some staff were unaware of the behavioral interventions required for the resident. These failures contributed to the incident of resident-to-resident abuse and placed other residents at risk.
Failure to Provide Appropriate Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in the resident not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. The resident, who had a history of vascular dementia with mood disturbance, recurrent depressive disorder, generalized anxiety disorder, and impulse disorder, frequently refused care, including showers and laboratory tests, and exhibited physically and verbally aggressive behaviors toward staff and other residents. Despite these ongoing behaviors, the facility did not adequately address the resident's customary routines, preferences, or choices, nor did it implement or document effective non-pharmacological interventions to manage the resident's dementia-related behaviors. The resident was observed propelling himself in a wheelchair throughout the facility, entering other residents' rooms, and becoming aggressive when redirected. On one occasion, the resident entered another resident's room, punched the resident in the arm, and attempted to strike her after being told he was in the wrong room. Staff interviews and record reviews revealed that the care plan did not reflect the need for close supervision, redirection, or specific interventions to prevent such incidents. Documentation was lacking regarding the identification and monitoring of behavioral triggers, the use of non-pharmacological interventions, and the effectiveness of care plan strategies. The care plan also failed to address the resident's preference for solitude and his tendency to become anxious and agitated around others. Additionally, the facility's documentation practices were insufficient, as the Treatment Administration Records did not record specific behaviors, non-pharmacological interventions, or the resident's aggressive episodes. Staff were unable to provide evidence of in-service training on dementia care and behavior management, and there was no clear process for communicating care plan changes to staff. The lack of comprehensive and updated care planning, documentation, and staff training contributed to the facility's failure to provide appropriate dementia care and to prevent further incidents of aggression and behavioral disturbances.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not providing adequate monitoring and documentation for multiple psychotropic medications. Specifically, the resident was prescribed Valproic Acid, Hydroxyzine, and Trazodone HCL for behavioral and psychiatric symptoms, but the required behavior monitoring documentation was not present on the Treatment Administration Record (TAR). The TAR only reflected side effect monitoring for antidepressants and did not include documentation of targeted behaviors or non-pharmacological interventions, as required by facility policy and pharmacy consultant recommendations. The resident in question had a complex medical history, including vascular dementia with mood disturbance, recurrent depressive disorder, generalized anxiety disorder, and impulse disorder. The resident had a history of aggressive behaviors, multiple hospitalizations for behavioral issues, and significant cognitive impairment as indicated by a low BIMS score. Physician orders and care plans called for close monitoring of behaviors, side effects, and the use of non-pharmacological interventions, but these were not consistently documented or implemented as required. Interviews and record reviews confirmed that the TARs for several months did not document specific behaviors exhibited by the resident, such as aggression, refusal of care, or other notable actions. The documentation was limited to nurse initials and did not reflect the monitoring of targeted behaviors or the use of non-pharmacological interventions, despite clear orders and policy requirements. This lack of documentation and monitoring constituted a failure to ensure the resident’s drug regimen was free from unnecessary drugs.
Failure to Document Required Annual Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that four employees, including an LVN, two CNAs, and the Activities Director, received the required minimum one-hour annual in-service training for Dementia and Behavior Management. Documentation for the annual training was not available for these staff members due to a change of ownership, which resulted in the loss of access to previous training records. Interviews with staff revealed uncertainty about whether or when the required training had been completed. The HR Payroll Coordinator confirmed that training records from the previous ownership were not retained, and the Executive Director stated that all staff were considered new hires after the change of ownership, with annual training still in progress for some employees. Record review showed that while some training had been completed in the current year, there was no documentation of prior annual training for the affected staff. The facility's policy requires all staff to be trained in dementia care practices upon hire and annually, but the lack of documentation meant compliance with this policy could not be verified for the identified employees. This deficiency was identified through interviews and record reviews conducted by surveyors.
Improper Disposal of Sharps and Contaminated Materials
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for four residents with cognitive impairments. Observations revealed that a retractable lancet device and blood-stained alcohol prep pads were left sitting in the horizontal drop slot of sharps containers in two separate rooms. These items were not fully disposed of inside the containers, leaving them accessible to residents. Record reviews indicated that the affected residents had diagnoses of Alzheimer's disease or dementia, with varying levels of cognitive impairment and self-care deficits. Interviews with the DON, an LVN, and the administrator confirmed that facility policy requires all sharps and contaminated items to be fully disposed of inside designated containers, and that staff are responsible for ensuring this is done immediately after use. The improper disposal of these items was directly observed and acknowledged by staff as not meeting facility policy.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and sanitation of food and equipment. Frozen vegetables, cookie dough, and sausage patties were found in unsealed bags and open boxes inside freezers and refrigerators, contrary to professional standards and facility policy. Staff interviews confirmed that these items should have been sealed to prevent contamination and spoilage, and that the observed practices did not meet expectations for food safety. Additional deficiencies were noted in the cleanliness of kitchen equipment and storage areas. A 1-gallon bottle of Worcestershire sauce was found with dry drippings on its side in the dry storage room, which staff acknowledged could attract insects and contaminate other food. The ice machine had visible dust and lint on its filters and top, and the deep fryer contained burnt, black oil with grease and food particles on its surfaces. The stove wall adjacent to the fryer was also soiled with oil splatter and food debris. Staff interviews revealed confusion about cleaning responsibilities and confirmed that the equipment was not being maintained in a sanitary condition as required by facility policy. Record reviews of facility policies indicated clear expectations for food storage, labeling, and kitchen sanitation, including regular cleaning of the ice machine and assignment of cleaning tasks to specific staff positions. Despite these policies, observations and staff interviews demonstrated that these standards were not being consistently followed, resulting in unsanitary conditions and improper food storage throughout the kitchen.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in three rooms on hallway 400, as evidenced by multiple observations of unclean conditions. Surveyors observed dirty floors with smeared, dried fruit stains, stained carpets with trash, debris, and food crumbs, and an alcohol pad with dried blood left on the floor. These unsanitary conditions persisted over multiple observations, with residents and staff confirming that cleaning was delayed or insufficient. Residents involved had significant medical and cognitive needs, including diagnoses such as pulmonary disease, heart failure, diabetes, dementia, kidney failure, Parkinson's disease, and mobility impairments. Their care plans indicated a need for assistance with daily activities and highlighted risks such as falls and infection. Residents reported that staff took a long time to clean their rooms and that requests for cleaning were not always addressed promptly. Interviews with housekeeping staff, the Housekeeping Supervisor, DON, LVN, and CNA confirmed that the observed conditions were not acceptable and posed risks for infection control and resident comfort. Staff acknowledged that all employees were responsible for maintaining cleanliness and that the presence of food debris, trash, and blood-contaminated items on the floor was contrary to facility policy and expectations for a homelike, sanitary environment.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in a lack of reasonable accommodation for their needs and preferences. For one resident with vascular dementia and severe cognitive impairment, the call light was observed to be pinned between two pillows underneath her, making it inaccessible. Her care plan specifically included an intervention to ensure the call light was available due to her risk for falls and need for extensive assistance with mobility and toileting. Another resident, diagnosed with unspecified dementia and a cognitive communication deficit, was found with his call light on the floor next to the head of the bed while he was sleeping, making it unreachable. This resident was dependent on staff for bed mobility, transfers, and toileting, and his care plan also required the call light to be within reach and for staff to encourage its use. Interviews with the DON, LVN, and CNA confirmed that all staff were responsible for ensuring call lights were accessible to residents, and that in-services on this topic had been conducted. Facility policy also required that each resident be provided with a means to call staff for assistance from their bed.
Failure to Maintain Cleanliness of Liquid Medication Bottles in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the proper storage and cleanliness of liquid medications in one of three medication carts checked. During an observation, dried drippings were found on bottles of Lactulose Solution and ProHeal Liquid Protein in the medication cart on the 300 hall. Staff interviews confirmed that nurses and medication aides were responsible for maintaining the cleanliness and organization of the medication carts and their contents. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and other nursing staff all stated that medication carts and bottles were to be cleaned daily and after each use, with regular monitoring by supervisory staff. Despite these stated responsibilities and monitoring practices, the presence of dried drippings on medication bottles indicated a lapse in maintaining the required standards of cleanliness. The facility's policy required nursing staff to keep medication storage and preparation areas clean, safe, and sanitary, but did not specifically address the maintenance of medication bottles. The deficiency was identified through direct observation and corroborated by staff interviews, highlighting a failure to adhere to established procedures for medication storage and cleanliness.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care for three residents, leading to a deficiency in care. Resident #7, a male with a history of osteomyelitis and myocardial infarction, did not receive wound care for his arterial wound on multiple occasions as documented in the administration reports. The care plan required daily wound care, but records show missed treatments on several dates in December and January. Resident #10, a female with a history of atherosclerosis and hypertension, also did not receive consistent wound care for her pressure wound. Her care plan specified daily treatment, yet the administration reports indicate numerous missed wound care sessions across December, January, and February. Similarly, Resident #11, a female with multiple diagnoses including diabetes and a history of traumatic amputation, did not receive the required wound care for her dehiscence wound on several occasions. Interviews with facility staff revealed systemic issues with providing wound care, particularly on weekends. The Treatment Nurse and ADON acknowledged ongoing problems with wound care not being administered, despite efforts to organize and communicate the necessary care. The Wound Care Doctor was not informed of the missed treatments, and the Interim-DON was unaware of the lapses until the issue was brought to his attention. The facility's skin policy outlines procedures for pressure injury prevention, but these were not effectively implemented, leading to the deficiency.
Failure to Provide Weekend Wound Care
Penalty
Summary
The facility failed to provide necessary wound care for a resident with a stage 3 pressure ulcer on the left buttock on two consecutive days. The resident, who was admitted with a history of Type 2 Diabetes Mellitus and a pressure ulcer, was supposed to receive daily wound care as per the care plan. However, the wound care was not documented or performed on the specified dates, as confirmed by interviews with staff and family members. Interviews with various staff members revealed a systemic issue with wound care not being provided on weekends. The Treatment Nurse, who was responsible for wound care during weekdays, stated that weekend nurses were expected to perform this task, but it was not completed for the resident in question. The lack of wound care documentation and performance was corroborated by the family member and several staff members, including LVNs and the ADON, who acknowledged the ongoing problem of missed wound care on weekends. The facility's failure to provide wound care as ordered was further highlighted by the Treatment Nurse's efforts to address the issue through in-services and education, which were not effective. The Wound Care Doctor was not informed of the missed wound care, and the Interim-DON was unaware of the lapses until after the fact. The facility's skin policy required regular audits and compliance checks, but these measures did not prevent the deficiency from occurring.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a male with a history of Type 2 Diabetes Mellitus and a stage 3 pressure ulcer, was admitted to the facility without a baseline care plan that addressed the necessary services for his condition. This omission was identified during a record review, which showed that the resident's baseline care plan was not generated, nor was a comprehensive care plan available. Interviews with the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (DON) revealed that the baseline care plan should have been created by the admitting nurse within 48 hours of the resident's admission. The ADON acknowledged that the absence of a baseline care plan could result in the resident not receiving the necessary care and services. The facility's policy mandates that a baseline care plan be initiated within 48 hours of admission, including initial goals based on various assessments and orders, which was not adhered to in this case.
Inadequate Discharge Planning for Resident Leaving AMA
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who left against medical advice (AMA). The resident, diagnosed with Type 2 Diabetes Mellitus and a stage 3 pressure ulcer, was admitted to the facility with specific care needs, including pressure ulcer management and incontinence care. However, a grievance report indicated that the resident did not receive necessary wound care, incontinence care, and medications, leading to dissatisfaction and the decision to leave the facility AMA. Interviews revealed a lack of communication and coordination among the facility staff regarding the resident's discharge. The Licensed Vocational Nurse (LVN) was informed by the family that the resident had a bad weekend and wanted to transfer to another facility. However, the nursing department was not informed of the resident's intention to leave, and the Social Worker did not confirm whether the resident arrived safely at home or another facility. The Assistant Director of Nursing (ADON) acknowledged that Adult Protective Services (APS) should have been contacted due to concerns about the safety of the resident's home environment. The Nurse Practitioner (NP) expressed that they were not informed of the resident's issues until after the resident left AMA, limiting the opportunity for intervention. The facility's policy required a physician's order for discharges unless the resident left AMA, and in such cases, the facility should discuss the risks with the resident and consider contacting APS. The Administrator noted that APS was eventually contacted, but not at the time of the AMA discharge, and concerns about the Social Worker's performance were identified, necessitating a Performance Enhancement Plan.
Medication Administration Failure
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of medications. On two consecutive days, the resident did not receive prescribed doses of Ciprofloxacin HCL, Sulfamethoxazole-Trimethoprim, and Spironolactone. These medications were intended for infection treatment and prophylaxis. The failure to administer these medications as ordered by the physician was identified through record reviews and interviews with staff and family members. Interviews revealed that the medications were not available during the weekend, and there was a lack of communication and coordination among the staff to address this issue. The family member of the resident reported the missing medications to the staff, but no satisfactory explanation was provided. Staff members, including LVNs and MAs, acknowledged the absence of medications and the inappropriate practice of borrowing medications from other residents, which is against facility policy and state law. The facility's policy requires medications to be administered safely, timely, and as prescribed, with any errors documented and reported. However, the staff failed to follow these procedures, leading to the resident not receiving necessary medications. The Interim-DON and other staff members confirmed that borrowing medications is not permissible and could lead to negative effects on residents. The deficiency highlights a breakdown in the facility's medication management system, risking the health and safety of the resident involved.
Failure to Document and Provide Incontinence Care
Penalty
Summary
The facility failed to maintain accurate medical records and provide documented incontinence care for a resident, leading to a deficiency in care. The resident, who was admitted with a history of Type 2 Diabetes Mellitus and a pressure ulcer, required substantial assistance for toileting hygiene and moderate assistance for other activities of daily living. Despite these needs, the facility did not document the provision of incontinence care, and the resident's family member reported having to provide this care themselves. The facility's records lacked a baseline or comprehensive care plan for the resident, and there was no documentation of education provided to the family regarding incontinence care. Interviews with facility staff revealed a lack of communication and documentation regarding the family's involvement in the resident's care. A Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) both acknowledged that the family member was providing incontinence care, but this was not reported to upper management or documented in the resident's records. The Assistant Director of Nursing (ADON) and Interim Director of Nursing (DON) stated that it was the responsibility of the nursing staff to provide care and report any issues to supervisors. The failure to document and communicate these issues could lead to risks such as infection, as noted by the LVN.
Failure to Include Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, specifically regarding their oxygen therapy needs. Resident #3, a female with dementia and chronic obstructive pulmonary disease (COPD), was receiving oxygen therapy as per her medical orders, but her care plan did not include this critical aspect of her treatment. Despite her oxygen saturation levels being within the prescribed range, the absence of a documented care plan for her oxygen therapy represents a significant oversight. Similarly, Resident #8, who has COPD and acute on chronic hypoxemic respiratory failure, was also receiving oxygen therapy. Her medical orders specified continuous oxygen at 3 liters per nasal cannula, yet her care plan failed to document this treatment. Observations confirmed that she was receiving the prescribed oxygen therapy, but the lack of a care plan could potentially lead to inconsistencies in her care. Resident #13, with severe cognitive impairment and chronic respiratory failure with hypoxia, was also affected by this deficiency. Her medical orders required continuous oxygen therapy to maintain saturation levels above 90%, which was not reflected in her care plan. The facility's failure to include oxygen therapy in the care plans of these residents could place them at risk of not receiving necessary care, as acknowledged by the Assistant Director of Nursing (ADON) and the MDS Coordinator, who cited staffing changes and transitions in electronic health records as contributing factors to the oversight.
Failure to Secure Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for a resident. Specifically, during a mechanical lift transfer, CNA B did not secure the brakes on the lift when lowering the resident to the bed, causing slight movement of the lift. Although the transfer was completed without incident, this oversight could have placed the resident at risk for falls or injury. The resident involved was a female with severe cognitive impairment, dependent on staff for transfers, and had a history of vascular dementia, muscle weakness, and hemiplegia following a cerebral infarction. Interviews with CNA B, the Director of Nursing (DON), and the Administrator revealed that the staff were trained on proper mechanical lift procedures, which included securing the brakes before lifting or lowering a resident. The DON and Administrator emphasized the importance of this step to prevent movement of the lift and potential injury. The facility's policy on mechanical lift safety guidelines also required that wheels be locked during transfers. Despite this training and policy, the failure to apply the brakes during the transfer was identified as a deficiency.
Failure to Update Care Plans for Transfer Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and time frames to meet their medical and nursing needs. Resident #4, who required mechanical lift transfer, did not have an updated care plan reflecting this need. Despite being transferred with a mechanical lift by CNAs, the care plan only mentioned assistance for all ADLs due to the risk of syncope collapse, without specifying the use of a mechanical lift. This oversight was noted during an observation and interview where the resident confirmed the use of a mechanical lift, and CNAs corroborated the change in transfer needs following the resident's recent hospitalization. Resident #7's care plan inaccurately reflected the need for a Hoyer lift transfer, although the resident had been using a 2-person assist transfer for several months. The physical therapist confirmed that the resident no longer required a Hoyer lift after recovering from a fracture. During an observation, CNAs assisted the resident with a 2-person transfer, consistent with the current needs, but the care plan had not been updated to reflect this change. Interviews with the DON and MDS Nurse revealed that the care plans were not accurately updated, despite good communication among staff regarding changes in residents' care needs. The Director of Nursing and MDS Nurse acknowledged the oversight in updating the care plans, attributing it to a lack of monitoring and review. The facility's policy on comprehensive care plans emphasizes the need for treatment goals, timetables, and objectives in measurable terms to prevent or reduce declines in residents' functional status. However, the failure to update the care plans for Residents #4 and #7 posed a risk of not providing the necessary care or services tailored to their current needs.
Failure to Suspend CNA After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse prevention policy when it did not immediately suspend a CNA after an allegation of physical restraint was reported by a resident's responsible party (RP). The policy, dated April 2021, mandates that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. However, the CNA continued to work on the days following the allegation, which was reported on July 31, 2024. The incident involved a resident who was severely cognitively impaired and required assistance with toileting. During a toileting transfer, the resident's RP, who was outside the bathroom, reported that the resident was physically restrained by a male CNA. The Director of Nursing (DON) was notified of the allegation and conducted an investigation, which included interviews with the CNAs involved. All CNAs denied the use of physical restraint and reported that the resident had become combative during the transfer. Despite the facility's policy, the CNAs were not suspended during the investigation. The DON acknowledged that the failure to suspend the CNAs could have placed residents at risk for continued abuse. The administrator, who was new to the facility, also stated that the CNAs should have been suspended according to the abuse policy, regardless of the number of witnesses present during the incident.
Failure to Apply Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #4 during transfers, as observed during a survey. Resident #4, a female with severe cognitive impairment and a history of muscle weakness, dementia, and mobility issues, was transferred using a mechanical lift without the proper application of brakes. The Lead CNA, responsible for the transfer, only applied one brake on the mechanical lift when lifting the resident from her wheelchair and did not apply any brakes when lowering her to the bed. This oversight was contrary to the training provided to CNAs, which emphasized the importance of applying brakes to prevent the lift from tipping over and causing potential injury or falls. Interviews with staff, including CNA E, the ADON, DON, and the Lead CNA, confirmed that the facility's protocol required brakes to be applied during mechanical lift transfers. The Lead CNA admitted to forgetting to apply the brakes due to nervousness, acknowledging the risk this posed to Resident #4. The facility's documentation on the use of the lifting machine did not specify when to use brakes, indicating a gap in procedural clarity. This deficiency in following established safety protocols during resident transfers was identified as a potential hazard for falls or injuries.
Failure to Secure Residents During Transport Leads to Injuries
Penalty
Summary
The facility failed to ensure the safety of residents during transportation, resulting in two residents falling and sustaining injuries while being transported back from a dialysis visit. The Maintenance Director, who was responsible for driving the facility vehicle, did not secure the residents properly, leading to the incident. Both residents were in wheelchairs and were not adequately strapped in, causing them to fall when the vehicle made a sharp turn. Resident #2, a female with multiple diagnoses including functional quadriplegia and end-stage renal disease, fell out of her wheelchair and sustained a scalp hematoma and a closed right fibula fracture. She was transported to the hospital for evaluation and treatment. Resident #3, who also has end-stage renal disease and uses a manual wheelchair, fell and suffered facial bruising and an abrasion to her left leg. She was also taken to the hospital, where it was confirmed that she did not sustain any fractures. Interviews with the residents and facility staff revealed that the Maintenance Director did not secure the residents with seatbelts, despite being trained to do so. The Director claimed that the wheelchairs were anchored to the floor, but the seatbelts were not in use at the time of the incident. The facility's policy requires all occupants to wear safety belts, and the failure to adhere to this policy led to the residents' injuries.
Removal Plan
- Facility Maintenance Director given disciplinary action of write up with two-day suspension.
- Driver competencies were performed for one Facility Driver and three other staff members designated as drivers.
- Facility restrictions put in place regarding who was able to drive residents on the vehicle allowing only the Facility Driver to drive residents.
- Facility Driver verified functionality of seatbelt and safety straps finding no defects.
- Facility in-service on teaching additional drivers properly how to strap residents on the wheelchairs to van when transporting.
- Facility in-service on and abuse and neglect.
Failure to Post Oxygen Signs for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided with appropriate care consistent with professional standards. Specifically, four residents who were on oxygen therapy did not have oxygen signs posted outside their rooms. This oversight could potentially place visitors, staff, and others at risk of not being aware of the oxygen use and the associated no-smoking requirement. Resident #5, a cognitively intact female with chronic obstructive pulmonary disease (COPD) and emphysema, was observed using oxygen therapy without a sign indicating oxygen use outside her room. Similarly, Resident #9, a male with severe cognitive impairment and acute respiratory failure, was also on continuous oxygen therapy without the necessary signage. Resident #10, a male with severe cognitive impairment and COPD, and Resident #11, a cognitively intact female with pneumonia and bronchiectasis, were both observed using oxygen therapy without the required signs outside their rooms. Interviews with facility staff, including an RN and the Director of Nursing (DON), confirmed that the facility's policy required oxygen signs to be posted outside rooms where oxygen therapy was in use. The purpose of these signs is to inform visitors and staff of the oxygen use and to prevent smoking in these areas, despite the facility being smoke-free. The responsibility for ensuring these signs were posted was assigned to the charge nurse on the hall.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to contact staff for assistance. The resident, a female with multiple diagnoses including functional quadriplegia and moderate cognitive impairment, was observed lying in bed with the call button hanging over an oxygen concentrator, approximately a foot and a half away, making it unreachable. The resident confirmed her inability to reach the button, which is crucial for her to call for help given her dependency on staff for various daily activities. During an interview, an LVN acknowledged that the call button should be within the resident's reach and confirmed that it was not. The LVN was unaware of how long the button had been out of reach and noted that the resident could not have moved it herself. The DON also confirmed that the call button should be accessible to residents in bed and emphasized that all staff are responsible for ensuring this during routine rounds. The facility's policy on answering call lights supports this requirement, stating that the call light should be within easy reach of residents when they are in bed or confined to a chair.
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. Resident #1, a [AGE] year-old female with diagnoses including Alzheimer's disease, heart failure, chronic obstructive pulmonary disease, anxiety disorder, and age-related physical debility, was admitted on 04/25/2024. However, the baseline care plan was not completed until 04/30/2024, five days after admission. The baseline care plan also failed to address the resident's high fall risk, despite the Morse Fall Risk Assessment completed on the day of admission indicating a high fall risk score of 60 and documentation of recent falls in the Admission Data Collection Tool. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the delay in completing the baseline care plan was due to the resident's admission occurring on a Friday evening when the MDS Coordinator was off for the weekend. The MDS Coordinator did not return to work until the following Monday, at which point the baseline care plan was completed. Both the DON and the MDS Coordinator acknowledged the oversight and the lack of a system to ensure baseline care plans are completed within 48 hours for weekend admissions. The facility's policy requires a baseline care plan to be developed within 48 hours to meet the resident's immediate needs, but this was not adhered to in this case.
Failure to Provide Timely CPR to Unresponsive Resident
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by the incident involving a resident who was found unresponsive. The resident, who had a full code status, was discovered by a CNA who immediately notified an RN. However, the RN did not know the proper procedures to follow for a full-code resident and did not initiate CPR immediately. This delay in providing CPR resulted in the resident not receiving timely resuscitation efforts. The resident had a history of coronary artery disease, osteomyelitis, diabetes mellitus with hyperglycemia, hypertension, vascular dementia, and hemiparesis. Despite the resident's care plan indicating a full code status, the RN failed to act promptly. The RN was unsure of the resident's code status and did not alert other nurses or initiate the code blue procedure. The delay in initiating CPR was confirmed by multiple staff interviews and record reviews. The facility's policies on emergency procedures and abuse and neglect were not followed. The RN's lack of knowledge and failure to act according to the facility's emergency procedures led to the resident not receiving the necessary life-saving measures in a timely manner. This incident highlighted significant gaps in staff training and emergency response protocols within the facility.
Failure to Provide Basic Life Support
Penalty
Summary
The facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel. A resident was found unresponsive by a CNA who immediately notified an RN. The RN checked for signs of life but did not know how to respond when she did not find a pulse and did not immediately start CPR or other life-sustaining measures. This resulted in the resident's wishes to be resuscitated not being honored. The resident had a history of coronary artery disease, osteomyelitis, diabetes mellitus with hyperglycemia, hypertension, vascular dementia, and hemiparesis affecting the left side as a late effect of a cerebrovascular accident. The resident's care plan indicated he was a full code status, meaning the facility was to attempt resuscitation should arrest occur. However, the RN failed to initiate CPR immediately upon finding the resident unresponsive, leading to a significant delay in emergency response. Interviews with staff revealed that the RN was unsure of the procedure to follow and did not alert other nurses in the facility about the resident's condition. The RN was later suspended and terminated following an investigation. The facility had not conducted any training on how to respond to such emergencies, relying instead on external CPR certification classes. This lack of training contributed to the failure to provide timely and appropriate emergency care to the resident.
Resident's Right to Dignified Existence Violated by Therapy Staff
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence when a therapy staff member made inappropriate comments and gestures towards a resident during therapy sessions. Therapy Staff G told the resident that she should be working and not talking, and jokingly mentioned that tape would be put on her mouth if she continued to talk. This incident left the resident feeling embarrassed and reluctant to engage in further communication during therapy sessions, which could potentially affect her rehabilitation progress. The resident, who had undergone a total left knee replacement and gallbladder removal, was receiving physical and occupational therapy as part of her treatment plan. During an interview, the resident reported that Therapy Staff G placed yellow paper tape over her mouth while she was talking to other residents during therapy. The resident's family member corroborated this account, stating that the incident made the resident very embarrassed and reluctant to speak during therapy sessions. Interviews with other therapy staff and residents did not reveal any additional instances of similar behavior. The Rehabilitation Director confirmed that Therapy Staff G had been counseled about professionalism following the incident. Despite the lack of physical evidence, such as the presence of tape in the therapy room, the resident's account and the family member's report indicate a failure to maintain a dignified and respectful environment for the resident during her therapy sessions.
Failure to Ensure Mechanical Lift Sling Was in Good Working Order
Penalty
Summary
The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing and the resident falling to the floor. Resident #37, who had a moderate cognitive impairment and was dependent on staff for various activities of daily living, including transfers, experienced pain and bruising as a result of the fall. The incident occurred while two CNAs were transferring the resident from a shower chair to a bed, and the resident was subsequently observed to have pain in his left leg and a bruise on his left wrist. X-rays were conducted, revealing no fractures. Interviews with staff, including CNAs and the Laundry Worker, confirmed that they had received prior training to check Hoyer slings for wear and tear. Despite this training, the sling used for Resident #37's transfer was not in good condition, leading to the incident. The facility's policy on the safe lifting and movement of residents, which mandates routine checks and maintenance of mechanical lift equipment, was not adequately followed, resulting in the deficiency.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that the handrails in the 100, 200, 300, and 400 halls had worn-off paint, exposing the wood beneath. This condition was noted on multiple occasions, indicating a lack of maintenance. Additionally, the soiled utility room and storage rooms in the 100 and 200 halls were found to be in poor condition. The mop basin had a black substance around it, the walls had chipped plaster and paint, and the floors were dusty with black marks and dried water stains. The storage room ceiling had a large brown water stain, and a light cover was missing. These issues were confirmed by the Maintenance Supervisor and the Administrator, who were unaware of the extent of the problems. Interviews with the Maintenance Supervisor and the Administrator confirmed the environmental deficiencies observed in the storage rooms where nursing supplies were kept. The Maintenance Supervisor acknowledged the dusty floors, black stains, and the presence of contaminated containers stored with clean supplies. He also confirmed that the water stain on the ceiling was due to a leak from the air conditioner, which had not been reported to maintenance. The Administrator confirmed the findings but was not aware of the issues prior to the survey. The facility's policy on cleaning and disinfection of environmental surfaces was reviewed, which stated that non-critical environmental surfaces, including floors and walls, should be cleaned regularly and when visibly soiled. However, the observations indicated that these policies were not being followed.
Failure to Post Ombudsman Information Accessibly
Penalty
Summary
The facility failed to post contact information for the Long Term Care Ombudsman program in a manner accessible to residents, particularly those who are wheelchair-bound. During a confidential group meeting, residents in wheelchairs reported that they did not know where to find the local Ombudsman information. An observation and interview with the Administrator revealed that the Ombudsman number was posted in the 100 hallway, but it was placed too high for wheelchair-bound residents to see. The Administrator acknowledged this issue and mentioned that the posting had been in the same location for years without prior complaints. A review of the facility's policy on displaying required notices and signage showed that it did not address accessibility for wheelchair-bound residents.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that residents had the right to examine the results of the most recent survey conducted by Federal or State surveyors. During a confidential group meeting, residents stated they did not know where or how to access the survey results. Observations revealed that the survey results were located in the lobby area, which required a code to access, making it not readily accessible to residents. Staff members, including an LVN and the DON, confirmed that the survey binder was in the lobby area and not easily accessible to residents without staff assistance. The Administrator was unaware that the survey results were not readily accessible and had not received recent complaints about this issue. The facility's policy on displaying required notices and signage did not address the survey results. This oversight could prevent residents from fully exercising their rights to be informed of the facility's survey history. The lack of accessibility to the survey results binder was confirmed through multiple observations and interviews with staff members, highlighting a significant deficiency in ensuring residents' rights to information.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately notify and consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, the facility did not inform the physician about a resident's ongoing behaviors of removing Prevalon boots, which were ordered for the healing of pressure ulcers. The resident, who had unstageable pressure ulcers on both heels, was observed multiple times without the boots on, despite physician orders. Staff interviews revealed that the resident frequently removed the boots, but this behavior was not consistently documented or reported to the physician, nor was it included in the care plan. The resident's care plan included interventions for pressure ulcer management, such as providing pressure-reducing surfaces and performing wound care as ordered. However, the failure to document and report the resident's behavior of removing the boots led to a lack of timely intervention and consultation with the physician. This oversight placed the resident at risk of delayed treatment and potential worsening of the pressure ulcers. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's behavior, contributing to the deficiency.
Failure to Resolve Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for two residents, Resident #383 and Resident #61, as required by their grievance policy. Resident #383's family had complained about verbal aggression from Resident #61, but no grievance was initiated or completed. The facility's records showed no documentation of the family's concerns, and no grievance was found for the months of January, February, and March 2024. The Social Worker (SW) admitted that a grievance should have been completed but was not because the issue was resolved on the same day. The Administrator also acknowledged that a grievance should have been completed based on the facility's policy. Resident #61 was moved to a different room due to complaints from her roommate's family about verbal aggression. The move was conducted without providing a written notice to Resident #61, who expressed dissatisfaction and fear of the Administrator. The SW and Administrator discussed the room change with Resident #61, who initially understood but later became upset. A meeting was held with the Ombudsman, Resident #61, her family, the SW, and the Administrator, where Resident #61 and her family voiced their dissatisfaction with how the situation was handled. Despite these concerns, no grievance was filed for Resident #61's complaint about the room change and the lack of written notice. The facility's failure to document and resolve these grievances as per their policy could place residents at risk for grievances not being addressed or resolved promptly. The SW and Administrator both acknowledged that grievances should have been completed for both residents but were not. The facility's policy on filing grievances and complaints clearly states that written grievances must be investigated, and a written report of findings should be submitted, which was not done in these cases.
Failure to Report Alleged Abuse by Administrator
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not report Resident #61's allegation of the Administrator slapping her hand when she was being forced out of her room. This failure to report the incident to the State Office and conduct a proper investigation could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Resident #61, an elderly female with diagnoses of anxiety, dementia, and other recurrent depressive disorders, alleged that the Administrator forcefully removed her from her room and slapped her hand when she tried to resist by holding onto the door frame. The incident was reported to the Ombudsman, who documented the resident's account of the event. Despite the resident's clear and consistent allegations, the facility did not report the incident to the State Office as required by their abuse policy. Interviews with facility staff, including the Social Worker (SW), Director of Nursing (DON), and the Administrator, revealed a lack of clarity and action regarding the reporting process when the alleged perpetrator is the abuse coordinator. The Administrator admitted that the allegation should have been reported to the State Office, and the Corporate Director of Operations confirmed that the abuse policy was not followed. The failure to report and investigate the allegation immediately resulted in a delay in addressing the resident's concerns and ensuring her safety.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one resident. Specifically, the facility did not ensure that Resident #61's allegation of the Administrator slapping her hand when she was forced out of her room was thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Resident #61, an elderly female with diagnoses of anxiety, dementia, and other recurrent depressive disorders, alleged that the Administrator had forcefully removed her from her room and slapped her hand when she tried to resist. Despite the resident's clear and consistent reports to the Ombudsman and the Social Worker (SW), the facility did not report the incident to the State Office or conduct a thorough investigation. The Administrator, who was also the abuse coordinator, did not suspend himself pending investigation and failed to report the allegation, citing the presence of witnesses as a reason. Interviews with various staff members, including the Director of Nursing (DON), SW, Maintenance staff, and Central Supply, revealed a lack of clarity on reporting procedures when the alleged perpetrator is the abuse coordinator. The Corporate Director of Operations eventually suspended the Administrator and conducted an investigation, but the initial failure to report and investigate the allegation immediately was a significant deficiency. The facility's abuse policy clearly states that all allegations should be reported and investigated thoroughly, which was not adhered to in this case.
Failure to Accurately Document CPAP Machine Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically regarding the use of a CPAP machine. The resident, who had diagnoses including COPD and chronic respiratory failure, was supposed to use a CPAP machine nightly. However, the resident's MDS did not reflect her refusal to use the CPAP machine, and there were inconsistencies in the documentation of her compliance. The resident's care plan noted her refusal to use the CPAP machine, and physician orders required documentation of her compliance, but this was not consistently done in the progress notes or MARs. Interviews with staff and family members confirmed that the resident often did not use the CPAP machine, and staff failed to document these instances as required by the physician's orders. The resident's respiratory therapy report indicated that she used the CPAP machine only 33 out of 90 days, with numerous specific dates in February and March where the machine was not used. Despite this, the MDS inaccurately reported that the resident had no behavioral symptoms, including rejection of care, and did not indicate the use of oxygen therapy. Interviews with the DON and ADON revealed a lack of awareness and proper documentation regarding the resident's non-compliance with the CPAP machine. The DON acknowledged that nurses should document refusals and follow physician orders, while the ADON mistakenly believed the resident was generally compliant. Further interviews with the LVN and respiratory therapist confirmed the resident's frequent non-use of the CPAP machine and the associated risks. The LVN noted that the resident had difficulty putting on the CPAP mask herself and required assistance, which was not always provided. The facility's policy on resident assessment emphasized the importance of accurate documentation to plan appropriate care, but this was not adhered to in the case of this resident, leading to a significant deficiency in care and documentation practices.
Failure to Ensure Resident Wore Prevalon Boots as Ordered
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, the facility did not ensure that the resident wore Prevalon boots while in bed as per the physician's orders. The resident, who had unstageable pressure ulcers on both heels, was observed multiple times without the prescribed Prevalon boots on her feet. Instead, the boots were found on a laundry hamper and a wheelchair. The resident's care plan included interventions to minimize the risk of skin breakdown and provide treatment as ordered by the physician, but these interventions were not consistently followed. Interviews with staff revealed that the resident had behaviors that led her to remove the Prevalon boots, but these behaviors were not documented in the care plan or progress notes. The LVN and CNA acknowledged that the resident's behaviors and the removal of the boots should have been reported and documented, but this was not done consistently. The ADON confirmed that the lack of documentation and reporting could result in the resident's wounds worsening and not healing. The facility's policy for pressure ulcer care was not obtained for review.
Failure to Ensure Resident Compliance with CPAP Machine
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan. Resident #30, who had diagnoses including COPD, chronic respiratory failure with hypoxia, and a sleep disorder, was not assisted in putting on her CPAP mask every night as per physician's orders. The resident's family member reported that facility staff were not placing the CPAP mask on the resident, and the resident herself confirmed she had difficulty putting the mask on by herself. The care plan did not address the resident's difficulty in putting on the CPAP mask, and there were multiple instances where the resident did not use the CPAP machine as required, which was not documented in the nursing progress notes as per physician's orders. Record reviews revealed that Resident #30 had a history of non-compliance with the CPAP machine, with significant gaps in usage documented by the respiratory therapy report. Despite the physician's orders to document compliance and notify the physician of non-compliance, the facility failed to consistently document the resident's refusal to use the CPAP machine. Interviews with the DON and ADON confirmed that the nurses should have been documenting instances of non-compliance and that the resident's non-use of the CPAP machine could exacerbate her COPD and lead to poor sleep quality and increased instances of sleep apnea. Interviews with staff, including LVN A, indicated that while some staff were aware of the resident's difficulty and attempted to assist her, there was a lack of consistent documentation and follow-through on the physician's orders. The respiratory therapist confirmed that the resident did not use the CPAP machine on numerous occasions, putting her at risk of poor sleep quality and increased sleep apnea. The facility's failure to ensure the resident's compliance with the CPAP machine and to document non-compliance as required by the physician's orders led to the identified deficiency.
Pharmaceutical Services and Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for three medication carts and four residents. Specifically, the facility did not have physician's orders documenting the prescribed amount of water for G-Tube flush before and after medication administration for one resident. Additionally, the facility did not administer prescribed medications according to physician's orders for another resident, and failed to administer nebulizer medications according to pharmacy policies and procedures for a third resident. Furthermore, the facility did not administer prescribed medications according to manufacturer specifications for two residents. The facility also failed to ensure that licensed staff did not sign off on the Controlled Drugs-Count Record form prior to counting and verifying that all controlled substances in the medication cart had been accounted for with the on-coming nurse at the change of shift. This was observed on two different halls. Additionally, liquid medications stored in medication carts on three halls were found to have dried drippings on the sides of the bottles, indicating a lack of proper storage and handling. The deficiencies were observed through various means including direct observation, interviews with staff, and record reviews. The issues identified could place residents at risk of harm or of not receiving desired outcomes from medications not administered according to physician orders. The facility's policies and procedures were not followed, leading to these deficiencies in pharmaceutical services and medication administration.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by reviews of residents' drug regimens by a licensed pharmacist were reported to the attending physician, the facility's medical director, and the director of nursing, and that these reports were acted upon for two residents. Specifically, the consulting pharmacist did not act upon the dispensing pharmacist's recommendations to administer prescribed medications according to manufacturer specifications. This failure placed residents at risk of not receiving medications as prescribed, potentially leading to adverse drug effects and a decline in their health status. For Resident #51, the pharmacist did not recommend administering Carvedilol with food, as indicated by the manufacturer's specifications. Similarly, for Resident #40, the pharmacist did not document any recommendations to take Spironolactone with food, despite the auxiliary label on the medication package. Both residents had significant medical histories, including vascular dementia, hypertension, and chronic renal disease for Resident #51, and hypertension and dementia for Resident #40. The failure to follow these recommendations was observed during medication pass observations and confirmed through record reviews and interviews with the pharmacist.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for three residents: Resident #65, Resident #24, and Resident #51. Resident #65 was prescribed Seroquel (quetiapine) to treat major depressive disorder, despite not showing symptoms of depression or psychosis. The resident's records indicated severe cognitive impairment and a history of Alzheimer's dementia with psychosis, but no recent symptoms justifying the continued use of the antipsychotic medication. The facility's Director of Nursing (DON) and MDS Nurse were not familiar with the risks associated with quetiapine, and multiple attempts to communicate with the resident's physician were unsuccessful. Resident #51 was prescribed Olanzapine to treat major depression, despite having severe cognitive impairment and no symptoms of delirium. The resident's records included diagnoses of Alzheimer's disease, anxiety disorder, depression, psychotic disorder, and schizophrenia. A gradual dose reduction (GDR) had been attempted, but the facility's DON and MDS Nurse were not knowledgeable about the specific indications for antipsychotic medications. The DON admitted to not knowing what Seroquel or Olanzapine were treated for and was unfamiliar with antipsychotic modifications. Resident #24 was prescribed Seroquel to treat restlessness and agitation, despite having severe cognitive impairment and no symptoms of depression or psychosis. The resident's records indicated a history of Alzheimer's, dementia, and vascular dementia, with fluctuating behaviors. A GDR was not attempted, and the antipsychotic medication was started by hospice. The facility's policy stated that antipsychotic medications should only be used when necessary to treat a specific condition, but this was not adhered to in these cases. The facility's DON and MDS Nurse were not familiar with the appropriate use of these medications, leading to the unnecessary administration of psychotropic drugs to the residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that two bottles of Dessert Sauce stored on a metal rack in the dry storage room had dried drippings around the lids. Additionally, a plastic bottle of Baking Soda had white residual around the sides, and several gallon containers of Vanilla, Soy Sauce, Worcestershire Sauce, and Imitation Maple Syrup Sauce had grease build-up, white powder residual, and dried drippings on the sides. An opened box of Corn Starch was not stored in a sealed container, and perishable foods such as potatoes were found to be wrinkled, soft to the touch, mushy, and sprouting. The facility also failed to store foods in the refrigerator in sealed containers, with several items observed to be improperly covered or not sealed at all. The ice machine was found to have white calcium build-up and rust, and it was reported to have been leaking water for approximately six months. Puree foods were prepared in unsanitary conditions, with the cook using a sink next to the food preparation table to puree various foods, despite the presence of food particles and water residual in the sink. Environmental checks in the kitchen revealed rusted vent covers, dark yellow substances on walls, and chipped paint on the ceiling. The facility's policy on food storage, revised in June 2019, was not followed, leading to these deficiencies.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for two dumpsters, leading to unsanitary conditions. Specifically, one of the plastic lids on the Front Load Dumpster was left uncovered, making the trash inside visible. Additionally, the side metal door on the Side Load Dumpster was not closed, also exposing the trash. These observations were made during a survey, and the Maintenance Director confirmed that dumpsters should always be kept covered to prevent insects and rodents from accessing the waste. The facility's policy on garbage receptacles, revised in June 2019, mandates that outdoor receptacles should have tight-fitting lids, doors, or covers and be kept closed to minimize the risk of food hazards and maintain sanitary conditions. However, these policies were not followed, as evidenced by the uncovered and partially opened dumpsters observed during the survey.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, leading to significant deficiencies in their care. For Resident #24, the facility did not properly discontinue an order for a puree diet, resulting in the resident not receiving the appropriate nutrition. Despite being on hospice care, there was no weight monitoring, and the dietary preferences and needs were not adequately communicated or documented by the staff, leading to potential nutritional deficiencies for the resident. For Resident #61, the facility failed to document an allegation of abuse accurately. The resident reported that the Administrator had slapped her hand during a forced room change, but this incident was not properly recorded in her medical records. The lack of documentation and investigation into the resident's claims of abuse and the improper handling of the room change process highlighted significant lapses in maintaining accurate and complete records. Resident #30's use of a physician-ordered CPAP machine was not accurately documented. Despite multiple instances of non-compliance with the CPAP machine, the facility failed to record these occurrences in the resident's progress notes as required by the physician's orders. This lack of documentation could lead to inadequate management of the resident's respiratory condition, as the staff was not fully aware of the resident's pattern of refusal to use the CPAP machine.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAPI) committee with the required members, specifically the Medical Director (MD) or a representative and the Infection Preventionist (IP), for 13 out of 14 meetings reviewed. Interviews and record reviews revealed that the MD attended only one QAPI meeting in 2023 and none in 2024, while the IP was absent from multiple meetings. The Director of Nursing (DON) confirmed that the facility held monthly QAPI meetings, but the MD and IP were frequently absent. The Administrator confirmed that the MD attended only quarterly QAPI meetings and had only attended one meeting in 2023 and none in 2024. The DON also mentioned that a new IP had just been hired, and she had been filling in as the IP. This lack of attendance by key members could lead to unidentified quality deficiencies and inadequate action plans, although the report does not specify any direct consequences or risks to residents.
Failure to Maintain Safe Operating Condition of Equipment
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, leading to a significant incident involving a resident. Resident #37, who had a moderate cognitive impairment and was dependent on staff for various activities of daily living, was being transferred using a Hoyer lift when the sling strap tore, causing the resident to fall to the floor. The resident experienced pain in his left leg and was observed to have a bruise on his left wrist. Despite prior training for CNAs to check Hoyer slings for wear and tear, the incident occurred, indicating a lapse in equipment maintenance and inspection protocols. Additionally, the resident's care plan had specified that the maintenance department should regularly check the Hoyer lift nets and straps to ensure they were safe for use, which was evidently not adhered to in this case. The facility also failed to keep the ice machine in the kitchen in safe operating condition. Observations revealed white calcium build-up and rust inside the ice machine, as well as water leaking from the ice maker into the ice bin. The Dietary Manager and Maintenance Director confirmed that the ice machine had been leaking for approximately six months, and despite being aware of the issue, the facility was still pending corporate approval for a replacement. This prolonged issue with the ice machine could potentially place residents at risk of foodborne illnesses due to the compromised condition of the equipment.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that the Administrator followed internal abuse policy, report allegations of abuse to the State Office, and conduct a thorough abuse allegation investigation. This failure was observed in the case of a resident who alleged that the Administrator had slapped her hand during a room transfer, an allegation that was not reported or investigated according to the facility's abuse policy. The resident involved, a female with diagnoses of anxiety, dementia, and other recurrent depressive disorders, reported that the Administrator had forcefully moved her out of her room and slapped her hand when she tried to resist by holding onto the door frame. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Despite the resident's report to the Ombudsman and the Social Worker, the allegation was not reported to the State Office, and no thorough investigation was conducted. The Administrator, who was also the abuse coordinator, did not suspend himself pending investigation and did not report the incident, citing the presence of witnesses as a reason. Interviews with various staff members, including the Director of Nursing, Social Worker, Maintenance staff, and Central Supply, revealed a lack of clarity on the procedure for reporting abuse allegations when the alleged perpetrator is the abuse coordinator. The Corporate Director of Operations eventually suspended the Administrator and conducted an investigation, but the initial failure to report and investigate the allegation immediately placed all residents at risk of continued abuse. The facility's policy on abuse, neglect, exploitation, or misappropriation was not followed, leading to a deficiency in the administration of the facility.
Infection Control Deficiencies in Equipment and Storage Practices
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Observations revealed that contaminated resident equipment was not stored in designated areas, and reusable water containers were placed directly on the floor in the Therapy Room. Additionally, supply boxes were stored on the floor in various storage rooms, and clean and dirty equipment were not stored on separate racks, leading to potential cross-contamination. Specific instances included a clean linen cart cover with a hole, and a yellow linen hamper left slightly open in the hallway, which should have been closed and stored in shower rooms when not in use. Interviews with staff confirmed these practices were not in line with the facility's infection control policies. Further observations showed that equipment such as oxygen concentrators, feeding poles, and nebulizer machines were stored inappropriately in hallways and storage rooms. The DON admitted that some of this equipment had been removed from resident rooms after discharges and had not been properly stored or disinfected. In the Therapy Room, reusable water bottles were consistently stored on the floor, contrary to proper storage practices. Interviews with staff members, including the Activities Staff and COTA, revealed a lack of awareness and adherence to proper storage protocols. In the storage rooms on the 100 and 200 halls, numerous issues were identified, including the presence of dust, stains, and improperly stored items. The Soiled Utility Room had a mop basin with a black substance around the sides, and various items were covered in dust and stains. Metal side rails and other equipment were stored on the floor, and clean supplies were stored alongside contaminated equipment. The Central Supply Room also had boxes of supplies stored on the floor. These observations and interviews highlighted significant lapses in the facility's infection control practices, as outlined in their policy and procedures on cleaning and disinfection of environmental surfaces.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident before a room change was made. Resident #61, an elderly female with diagnoses of anxiety, dementia, and recurrent depressive disorders, was moved to a different room without receiving the required written notice. The resident had a history of conflicts with roommates and was reported to have been verbally aggressive by the family of a new roommate. The facility's administrator decided to move Resident #61 to prevent further escalation, but did not provide the mandated five-day written notice prior to the move. The incident was documented in various records, including the resident's face sheet, history and physical, quarterly MDS assessment, and social worker progress notes. The social worker and administrator discussed the room change with Resident #61, who initially verbalized understanding but later became upset when the move was executed. A meeting involving the local Ombudsman, the administrator, the social worker, Resident #61, and her family members was held to address the family's dissatisfaction with how the situation was handled. The Ombudsman case file revealed that Resident #61 felt forcefully removed from her room and was not given proper notice or an investigation into the complaint against her. The resident and her family expressed dissatisfaction with the administrator's handling of the situation, feeling that her rights were violated. The facility's policy on room changes requires advance notice, which was not provided in this case, leading to the deficiency noted in the report.
Failure to Properly Secure Suprapubic Catheter
Penalty
Summary
The facility failed to ensure that a resident's suprapubic catheter was properly secured, which placed the resident at risk of pain and trauma. The resident, who had a history of urinary tract infection, dementia, and a suprapubic catheter, was observed with a catheter that was not properly secured. The catheter patch was dated over a month prior, and the latch was not functioning correctly. Both a CNA and an LVN acknowledged the issue but did not specify how long the catheter had been improperly secured. The facility's care plan and physician orders indicated that the catheter should be secured to the thigh and checked every shift, but these protocols were not followed consistently. Interviews with staff, including CNAs, LVNs, and the DON, revealed that there was a lack of communication and follow-up when catheters were found to be improperly secured. The DON stated that both nurses and CNAs were responsible for checking the catheters, but there was no clear process for reporting and addressing issues. The last in-service training on catheter care was conducted in February, but the frequency of such training was not specified. This deficiency highlights a failure in adhering to established protocols for catheter care and communication among staff, leading to potential harm for the resident.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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