Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at El Paso Health & Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and preparation practices were not followed during kitchen observations. A dietary staff member left boneless pork loin thawing in a sink without running cold water, several refrigerated items were found open, unlabeled, or past their use-by date, and a puree diet demonstration showed a staff member handling a blender lid with bare hands and placing it into cooked food. The DON and Administrator stated these practices created cross-contamination concerns.
Missing Care Plan for Psychotropic Medication: A resident with stroke, DM2, dementia, and DVT had a BIMS score of 0 and was prescribed Mirtazapine 7.5 mg HS for appetite stimulation, but the psychotropic medication was not included in the care plan. The DON, ADON, MDS nurse, and Administrator stated psychotropics should be care planned so staff can monitor for side effects and guide care, and the facility policy required measurable objectives, timeframes, and interventions.
Medications were left unattended at a resident’s bedside in clear cups, including crushed meds mixed with pudding and an unknown liquid, while the room door was open and another resident was present. The resident said the nurse had left the meds for later after breakfast. The resident’s MAR included multiple AM meds, and staff including an LVN, the DON, and the Administrator stated meds were not to be left unattended and should be observed until taken; the facility policy also required meds to be administered at the time prepared and not pre-poured.
A resident with severe cognitive and physical impairments was not provided with necessary fingernail care, as observed by surveyors who found long, dirty fingernails with chipped nail polish. Despite care plans and staff protocols requiring regular nail maintenance, staff interviews confirmed that the expected grooming was not performed, resulting in unmet personal hygiene needs.
Two residents requiring oxygen therapy were found using oxygen concentrators with visibly dusty filters that had not been cleaned as recommended. Staff interviews confirmed that cleaning and monitoring of the filters was a shared responsibility among nursing staff, CNAs, and Central Supply, but the filters were not maintained according to the manufacturer's guidelines or facility policy.
The facility failed to maintain a full-time Director of Nursing (DON) from early December 2024 to mid-January 2025. Despite efforts to recruit a new DON through social media and other channels, the position remained vacant, leading to concerns about nursing oversight and service management. The absence of a DON was confirmed through staff hour reviews and interviews with the facility's administration and HR.
A resident with a history of falls and visual impairment was unable to use the restroom safely due to non-functioning lights in her room. Despite reporting the issue to a CNA, the problem was not entered into the facility's work order system, delaying resolution. The facility's protocol for reporting maintenance issues was not followed, posing a risk to the resident's safety.
A resident's transfer using a mechanical lift was compromised when CNA A failed to secure the brakes, causing the lift to move slightly. Despite training on proper lift use, the oversight occurred during a transfer involving a resident with multiple health conditions. The facility's policy required securing the brakes to prevent injury.
A resident was improperly restrained with pillows under his mattress, restricting movement without medical necessity. The CNA involved claimed to have been instructed by an RN, despite knowing it was against policy. The facility's policy prohibits restraints for convenience, yet this practice was not documented or authorized.
A resident with multiple health conditions, including cerebral palsy and paraplegia, was found with their call light out of reach, contrary to their care plan. The resident confirmed they could not reach the call button, and staff acknowledged the oversight, recognizing the risk of delayed assistance. The facility did not provide the call light policy upon request.
A resident with multiple health conditions, including cerebral palsy and paraplegia, was identified as a fall risk. The care plan required a fall mat to be placed next to the bed, but it was found six feet away, leaning against a dresser. Staff interviews revealed that the mat was not consistently placed as required, increasing the risk of injury.
A resident's care plan was not updated to remove an outdated intervention for wall padding, despite the behavior no longer being exhibited since 2021. The facility's staff, including the ADON, MDS Coordinator, DON, and Administrator, acknowledged the oversight and the importance of timely care plan revisions to prevent confusion and ensure accurate care.
A resident with multiple health conditions requiring substantial assistance with ADLs did not receive adequate nail care, as their fingernails were observed to be long, jagged, and dirty. Despite the facility's policy and care plan emphasizing regular nail maintenance to prevent infection and skin issues, staff interviews revealed a lack of awareness and follow-through on the resident's nail care needs.
A resident with severe cognitive impairment and dysphagia did not receive continuous enteral feeding as ordered by the physician, as the feeding pump was found turned off during an observation. The nursing staff was unaware of the reason for the machine being off, and the facility's policy on enteral nutrition was not followed, potentially risking the resident's nutritional status.
The facility failed to maintain a sanitary environment for two residents and one room, as feeding pump machines were found dirty with unknown substances. A resident with gastrostomy status and dysphagia had a feeding pump with a white and brown-ish substance, while another resident's pump was greasy and dirty with various substances. The DON acknowledged the lack of a monitoring tool for cleaning, despite the facility's manual recommending cleaning after each use to prevent contamination.
The facility failed to provide adequate nail care for two residents with impaired cognition and health issues, resulting in long and dirty fingernails. Despite care plans requiring assistance, interviews revealed inconsistencies in nail care provision by CNAs and nursing staff, with a lack of documentation and potential risks of infection and injury.
The facility failed to provide adequate foot care for two diabetic residents with impaired cognition, leading to untrimmed and uncleaned toenails and no scheduled podiatry appointments. Interviews revealed that residents had not received podiatry care since a change in facility ownership, and staff confirmed the absence of podiatry visits. The DON and ADONs acknowledged the lack of care and the potential risks of infection and ingrown toenails, despite the facility's Nail Care manual emphasizing the importance of regular nail care.
A facility failed to accurately reflect a resident's fall history in their MDS assessment, despite documented incidents and acknowledgment from family, physician, and MDS Coordinator. The resident, with Alzheimer's and mobility issues, had a care plan addressing fall risks, but the MDS oversight potentially impacted care. The DON was unaware of the MDS process specifics.
A resident with Alzheimer's and a history of falls did not have a fall mat included in their care plan, despite physician orders. Family members and staff confirmed the absence of the mat, which was crucial for the resident's safety. The facility's manual requires such interventions to be documented, but this was not followed, posing a risk to the resident.
A resident with Alzheimer's and impaired mobility was at high risk for falls, yet the facility failed to implement a physician-ordered fall mat. Despite the resident's history of falls and attempts to get out of bed without assistance, the fall mat was not placed, and the care plan was not updated, leading to a deficiency.
The facility failed to maintain food safety and storage standards, with moldy foods found in freezers, improper storage of cleaning chemicals, and unclean surfaces in the kitchen. Staff interviews revealed a lack of adherence to policies, risking contamination and foodborne illness.
The facility failed to maintain essential kitchen equipment, with freezer #2 having significant ice buildup and missing stove knobs, leading to potential food safety risks. The new QR code system for maintenance requests was not fully operational, causing delays in addressing these issues.
The facility failed to provide reasonable accommodation for residents' needs, particularly regarding call light accessibility and room functionality. Several residents had call lights out of reach, despite their care plans requiring them to be accessible, posing risks for those with mobility and cognitive impairments. Additionally, a resident struggled with a malfunctioning room door, which had not been promptly addressed by maintenance.
The facility failed to develop comprehensive care plans for two residents with significant functional limitations in their range of motion. Both residents were dependent on staff for daily activities and had severe impairments, yet their care plans did not include necessary interventions for their conditions. Despite having therapy orders, these were not reflected in the care plans, and the facility lacked a restorative program, increasing the risk of contractures and decreased mobility.
The facility failed to provide individualized activities for two residents, impacting their well-being. One resident, with a history of weakness and falls, was not given materials for in-room activities despite preferring to stay in his room due to leg pain. Another resident, with Alzheimer's and depression, participated in group activities but lacked materials for preferred activities like coloring afterward. Staff interviews revealed confusion over responsibility for providing these materials, leading to residents experiencing boredom.
The facility failed to ensure accurate documentation of Texas OOH DNR orders for several residents, leading to potential issues with honoring their healthcare wishes. Errors included incorrect signatures, missing dates, and lack of documentation for legal authority, affecting the validity of the DNR forms.
A resident with Alzheimer's and anorexia did not receive the necessary encouragement and assistance during meals as per her care plan. Staff failed to offer a second choice or provide encouragement, risking potential weight loss and ADL decline. Interviews revealed expectations for staff to encourage eating and offer alternatives, which were not met.
A resident with severe cognitive impairment and multiple health conditions did not receive necessary nail care, resulting in long and dirty fingernails. Despite facility protocols requiring CNAs to trim nails weekly, the responsible CNA failed to notice the issue, and charge nurses did not ensure compliance. This neglect posed a risk of cross-contamination and infection.
A resident received Lorazepam on a PRN basis for more than 14 days without a stop date, contrary to the facility's policy. The medication was prescribed for anxiety and to address lip-biting behavior, but the order lacked the required 14-day limit. The interim DON confirmed the necessity of a stop date to prevent unnecessary medication use, as per the facility's policy.
A facility failed to maintain proper infection control practices, as observed in two incidents. A CNA improperly performed incontinent care by wiping from back to front, risking infection for a resident with heart failure. Additionally, another resident's oxygen nasal cannula was not stored in a plastic bag when not in use, contrary to facility policy, potentially leading to contamination. Staff interviews confirmed these lapses, highlighting a need for adherence to infection prevention protocols.
A resident alleged that a Driver was rough during a transfer into a van, but the facility failed to immediately suspend the Driver as per their abuse prevention policy. Despite the resident's report, the Driver continued to work and transport another resident before being suspended. Interviews with staff and other residents did not corroborate the allegation, and assessments found no injuries. The facility acknowledged the failure to follow policy.
The facility failed to provide a safe, functional, sanitary, and comfortable environment, with issues such as stained floors and ceilings, broken tiles, non-functional faucets, and a strong urine smell in B-Hall. A resident's room had persistent urine odor and wet toilet paper on the floor. Maintenance issues, including lack of hot water in C-Hall, were not adequately addressed.
A resident reported a dead roach in the light fixture above his bed that had been there since January 2024. Despite informing staff, the issue was not resolved. Housekeeping staff were unaware of the problem and admitted responsibility for cleaning the fixture, which was not done according to the facility's policy.
A facility failed to include the use of cushion boots in a resident's care plan, despite the resident's need for them to prevent heel pressure ulcers. The resident, who was cognitively intact and had multiple conditions including Stage 4 pressure ulcers, repeatedly informed CNAs about the need for the boots without success. Staff acknowledged the importance of the boots, and the DON confirmed they should have been included in the care plan.
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, leading to improper wound care and inconsistent use of cushion boots. The resident's care plan and physician orders were not followed, resulting in an exposed wound and a lack of proper labeling of dressings.
The facility failed to properly dispose of garbage and refuse, as observed with two dumpsters having open sliding doors and trash on the ground. Staff interviews confirmed that the dumpsters were not being closed after use, and trash was not being picked up, posing risks of contamination and attracting pests.
A facility failed to maintain infection control when an LVN placed a nasal cannula found on the floor back on a resident's face without replacing it. Staff interviews confirmed that the proper protocol is to discard and replace contaminated tubing, as per the facility's policy.
Food Storage, Thawing, and Preparation Cross-Contamination
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during multiple kitchen observations. On 8/4/25, two bags of boneless pork loin were observed in a gray plastic receptacle in the kitchen sink with the faucet off and no water running. The dietary staff member stated that if the pork was to be used the same day, it had to be thawed under cold running water and that thawing at room temperature was not acceptable. During the same kitchen observation on 8/4/25, refrigerator #1 contained a square clear receptacle of refried beans with a clear lid that was not labeled and was not fully closed, and two clear Ziploc bags containing jalapenos and onions that were open and not sealed. Refrigerator #2 contained an object approximately 15 inches long wrapped in brown butcher paper and sealed in plastic wrap that was unlabeled and undated. Refrigerator #3 contained a clear square plastic receptacle labeled as beef with a prepared date of 7/17/25 and a use-by date of 7/23/25. The dietary staff member stated that food items in the refrigerators needed to be properly closed, sealed, and labeled, and that unlabeled food needed to be disposed of because staff could not determine when it was received. On 8/5/25, during a puree diet and mechanical chop demonstration, a dietary staff member placed breaded chicken breasts and chicken stock into a blender, then removed the lid with a bare hand to add more stock. The lid was then placed into the uncovered container where the cooked breaded chicken was being processed. The staff member stated the blender lid should not have been in the container with the cooked food because of cross-contamination concerns. She had washed her hands at the beginning of the demonstration but did not rewash them after touching the contaminated lid. The Director of Food and Nutrition and the Administrator later stated that improperly sealed food, improper thawing, and utensil contact with bare hands could lead to cross-contamination and bacterial growth.
Missing Care Plan for Psychotropic Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #9 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs. Resident #9 was an [AGE]-year-old female admitted on 06/09/21 with a history of stroke, type 2 diabetes, dementia, and deep vein thrombosis. Her quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and also indicated that she was taking an antidepressant. Record review showed that Resident #9 was prescribed Mirtazapine 7.5 mg by mouth at bedtime, starting 05/07/25, for appetite stimulation, but the care plan dated 07/31/25 did not include this psychotropic medication. During interviews, the Regional MDS Nurse, DON, ADON, and Administrator stated that psychotropic medications were to be included in the care plan so staff could monitor for side effects and provide the correct plan of care. The facility policy stated that the comprehensive care plan must include measurable objectives, timeframes, and interventions to meet the resident’s identified needs.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for one resident reviewed for medication storage. During an observation and interview, two clear plastic measuring cups were found at the resident’s bedside table with the room door open: one cup contained crushed medications mixed with pudding and the other contained an unknown clear liquid. The resident stated the nurse had left the medications for her to take after breakfast, and her roommate was present in the room. The resident’s record showed diagnoses including high blood pressure, recurrent depressive disorder, constipation, and rhabdomyolysis, and a BIMS score of 14 indicating intact cognitive function. The resident’s MAR listed morning medications including Bupropion HCL, Jardiance, Losartan Potassium, Miralax, Carvedilol, Docusate Sodium, Lactulose, and Simethicone. In interviews, an LVN stated medications were not to be left unattended and should be disposed of if a resident did not want to take them, and that staff were responsible for ensuring medications were not left unattended. The DON and Administrator also stated medications were not to be left at bedside unattended and that if a resident did not want to take medication at the time of administration, the medications were to be disposed of. The facility policy stated medications are administered at the time they are prepared, are not pre-poured, and staff should observe the resident take the medications.
Failure to Provide Adequate Fingernail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and physical limitations, including hemiplegia and hemiparesis following a stroke, was not provided with adequate fingernail care. The resident required moderate assistance with personal hygiene, as documented in the Minimum Data Set (MDS), and the care plan specified that nursing staff should check, trim, and clean nails on bath days and as necessary. However, during observation, the resident was found to have fingernails approximately one inch long with visible dirt underneath and chipped nail polish. The resident was unable to communicate preferences regarding nail length. Interviews with facility staff, including CNAs, LVNs, the ADON, and the DON, confirmed that nail care was expected to be provided during scheduled showers or as needed, with nurses responsible for diabetic residents. Staff acknowledged the importance of maintaining short and clean nails and recognized the infection control risks associated with long, dirty fingernails. Despite these protocols, the resident's nails were not maintained according to the care plan and facility policy, resulting in unmet personal hygiene needs.
Failure to Maintain Clean Oxygen Concentrator Filters for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For both residents, observations revealed that the oxygen concentrator filters in use were visibly dusty and had not been cleaned according to the recommended schedule. Resident #2, a male with diagnoses including lymphedema, muscle weakness, obstructive sleep apnea, and peripheral vascular disease, was observed using an oxygen concentrator with a dusty filter while receiving oxygen via nasal cannula. Resident #3, a male with a history of cerebral infarction, metabolic syndrome, dysthymic disorder, cognitive communication disorder, hypertension, and muscle weakness, was also observed using an oxygen concentrator with a dusty filter while on oxygen supplementation for acute hypoxic respiratory failure. Interviews with facility staff, including an LVN, ADON, and DON, confirmed that the responsibility for cleaning and monitoring the oxygen concentrator filters was shared among nursing staff, CNAs, and Central Supply, with a cleaning schedule of once per week as per the manufacturer's manual. Staff acknowledged that failure to clean the filters could lead to infection control issues and possible equipment malfunction. Record reviews and staff statements indicated that the filters had not been maintained in accordance with professional standards of practice, as required by the facility's policies and the manufacturer's recommendations.
Facility Lacks Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure they had a full-time Director of Nursing (DON) from December 6, 2024, through January 15, 2025. This deficiency was identified through observation, interviews, and record reviews. The absence of a full-time DON was confirmed by reviewing staff hours and through multiple interviews with the facility's Administrator, Assistant Directors of Nursing (ADONs), and Human Resources (HR). The last full-time DON's official last day was December 5, 2024, and since then, the facility has not had a full-time or interim DON. The facility was actively seeking to hire a new DON using social media, websites, and word of mouth, but had not succeeded by the time of the survey. The Administrator and ADONs acknowledged the lack of a DON and expressed concerns about the potential risks associated with this deficiency, such as a lack of nursing oversight and the possibility of tasks being performed outside the scope of practice for some nurses. The HR representative also highlighted the importance of a DON in managing the nursing department and ensuring that residents receive all necessary services. Despite these efforts, the facility did not have a policy for hiring a DON and was following state guidelines in their recruitment process.
Failure to Address Lighting Issue in Resident's Room
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for a resident by not ensuring that the lights in the resident's room and restroom were functioning. This deficiency was observed when the resident attempted to use the restroom but was unable to do so safely due to the darkness, as the lights would not turn on. The resident, who has a history of falls and impaired visual function, reported the issue to a CNA, but the problem was not addressed promptly. The CNA acknowledged being informed about the lighting issue by the resident but did not use the facility's work order system to report the problem. The CNA was unable to locate the charge nurse and, being occupied with other duties, did not follow through with the necessary steps to ensure the issue was resolved. The facility has a system in place for reporting maintenance issues, including QR Scan codes for easy access, but this protocol was not followed in this instance. Interviews with the Maintenance Director and other staff confirmed that all facility staff were trained to use the work order system and were aware of the importance of reporting maintenance issues immediately. The Maintenance Director was only informed of the lighting issue shortly before the surveyor's observation, indicating a delay in addressing the problem. The failure to report and fix the lighting issue in a timely manner posed a risk of falls and injury to the resident, who relies on a well-lit environment due to her visual impairments.
Failure to Secure Mechanical Lift Brakes During 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, the brakes on the lift were not engaged, causing the lift to move slightly. This incident involved a resident who was dependent on staff for transfers and had a history of diabetes, hypertension, pulmonary embolism, and an unstageable pressure ulcer. The resident's care plan required assistance from two people for transfers using a mechanical lift. During the transfer, CNA A and CNA B assisted the resident, but CNA A did not secure the brakes on the mechanical lift, both when lifting and lowering the resident. Interviews with CNA A and CNA B revealed that they had received training on the proper use of mechanical lifts, including securing the brakes. However, CNA A admitted to forgetting to secure the brakes, which posed a risk of injury to the resident or staff. The facility's policy on hydraulic lifts emphasized the importance of locking the base wheels according to the manufacturer's recommendations to ensure safe transfers.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as observed during a survey. A resident was found with pillows placed under his mattress, which restricted his movement and was not required for medical treatment. This setup was intended to prevent the resident from rolling off the bed, as stated by a CNA, who had been using this method for some time without being instructed otherwise. The resident, a male with multiple diagnoses including dementia and atrial fibrillation, was newly admitted to the facility. His care plan did not document any behavioral issues related to getting out of bed, and there was no order for the use of pillows as a restraint. The facility's policy prohibits the use of restraints for discipline or convenience, yet the pillows were used without proper authorization or documentation. Interviews with staff revealed a lack of awareness and communication regarding the use of restraints. The CNA involved claimed to have been instructed by an RN to use the pillows, despite knowing it was against policy. The DON and ADONs were unaware of this practice and confirmed that it was inappropriate. The facility's policy emphasizes a restraint-free environment, but the incident highlighted a gap in adherence to this policy.
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 the resident's needs and preferences. The resident, who has cerebral palsy, depressive disorder, muscle weakness, lack of coordination, intellectual disability, seizures, and paraplegia, was observed lying in bed with the call button placed on a bedside dresser approximately four feet away, making it inaccessible. The resident confirmed his inability to get up from bed independently and expressed unawareness of how long the call button had been out of reach. The resident's care plan specifically included interventions to ensure the call light was within reach to prevent falls and meet the resident's needs. During interviews, both the LVN and the DON acknowledged the importance of the call light being within reach to alert staff when assistance is needed. The LVN noted that the call button was likely moved during recent patient care and not returned to an accessible position. The DON and the Administrator both recognized the risk of delayed assistance if the call button is out of reach, emphasizing the responsibility of all staff to ensure it remains accessible. Despite requests, the facility did not provide a copy of the call light policy before the survey exit.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical and nursing needs. The resident, a male with cerebral palsy, depressive disorder, muscle weakness, lack of coordination, intellectual disability, seizures, and paraplegia, was identified as having a potential for falls due to impaired mobility. The care plan included an intervention for a fall mat to be placed next to the bed while the resident was lying down. However, during an observation, the fall mat was found leaning against a dresser approximately six feet away from the bed, and the resident was unaware of how long it had been there. Interviews with staff, including an LVN and the DON, revealed that the fall mat was not consistently placed next to the resident's bed as required by the care plan. The LVN acknowledged that the resident was a fall risk and that the fall mat should have been in place, but it was not clear how long it had been missing. The DON emphasized the importance of following the care plan to reduce the risk of injury. The facility's policy stated that each resident should have a person-centered comprehensive care plan developed and implemented to meet their needs, but this was not adhered to in the case of the resident in question.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to review and revise the care plan for a resident after each assessment, leading to outdated information being used in the resident's care. The resident, a male with cerebral palsy, depressive disorder, muscle weakness, lack of coordination, intellectual disability, seizures, and paraplegia, had a care plan intervention from 2021 that required padding on the wall to prevent injury from hitting it. However, this intervention was no longer applicable as the resident had not exhibited the behavior since 2021, and the care plan was not updated to reflect this change. During observations and interviews, it was noted that the resident's care plan still included the outdated intervention, and the wall was not padded in the resident's current room. The Assistant Director of Nursing (ADON) and the MDS Coordinator acknowledged that the care plan should have been updated to remove the intervention, as it was no longer necessary. The Director of Nursing (DON) and the Administrator also recognized the importance of timely care plan revisions to prevent confusion and ensure accurate care. The facility's policy emphasized the need for person-centered comprehensive care plans that reflect current interventions to meet residents' needs.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the facility did not ensure that the resident's fingernails were trimmed and cleaned, which was a part of the care plan to maintain good personal hygiene and prevent potential skin integrity issues. The resident, who had multiple diagnoses including cerebral palsy, depressive disorder, and paraplegia, required substantial assistance with personal hygiene. Observations revealed that the resident's fingernails were long, jagged, and dirty, with brown/black discoloration underneath, and the resident expressed a desire to have them trimmed. Interviews with facility staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), indicated that nail care was typically performed on Sundays or as needed, either by Certified Nursing Assistants (CNAs) or nurses. However, there was a lack of communication and follow-through regarding the resident's nail care needs, as staff were unaware of when the resident's nails were last trimmed. The facility's policy on nail care emphasized regular maintenance to promote cleanliness and prevent infection, yet this was not adhered to, resulting in the deficiency.
Failure to Administer Continuous Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not provide the correct feeding through the gastrostomy tube as ordered by the physician. The resident, a female with severe cognitive impairment and multiple diagnoses including cerebral infarction and dysphagia, was observed with the feeding pump turned off, contrary to the physician's order for continuous feeding from 0600 to midnight. This oversight was noted during an observation when the resident was found lying in bed with the feeding pump off, and the LVN was unaware of the reason for the machine being turned off. Interviews with the LVN and the Director of Nursing (DON) revealed that the nursing staff was responsible for ensuring that orders were followed, and the failure to do so could lead to weight loss and malnutrition if it were a recurring issue. The resident's weight records showed a slight decrease from 130.0 lbs to 129.6 lbs over a few months, but no significant weight loss was reported. The facility's policy on enteral nutrition emphasized the responsibility of the Nursing Services Department to administer tube feedings as ordered by the physician, highlighting a lapse in adherence to this policy.
Failure to Maintain Sanitary Feeding Equipment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for two residents and one room, as observed during a survey. Resident #2's feeding pump machine was found with a white unknown substance on its blue face and a brown-ish substance on top. Resident #5's feeding pump machine was greasy and dirty, with brown-ish substances around the pole and power cord, a reddish substance on the left side, and a black smeared substance on the right side. Additionally, the feeding pump machine in room [ROOM NUMBER]B was covered with an unknown brown-ish substance. Resident #2, a female diagnosed with gastrostomy status, dysphagia, and malnutrition, was dependent on tube feeding and water flushes. Her care plan required continuous enteral feeding with Jevity formula. Resident #5, a male diagnosed with gastrostomy status and gastro-esophageal reflux disease, was also marked for feeding tube use. Both residents' feeding pump machines were observed to be dirty, which could potentially lead to infection due to improper care practices. The Director of Nursing (DON) acknowledged that the nursing staff was responsible for cleaning the feeding pump machines and surrounding areas. However, there was no log or monitoring tool to ensure the cleaning was performed. The facility's Feeding Pump Manual recommended cleaning the pump after each feeding set use to prevent bacterial contamination, but this was not adhered to, as evidenced by the observations. The facility's Infection Control Plan emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not achieved in this instance.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to two residents, specifically in maintaining good personal hygiene, including nail care. Resident #3, a male with severely impaired cognition and multiple health issues such as muscle wasting and Type 2 Diabetes Mellitus, required substantial assistance with personal hygiene. His care plan indicated the need for extensive assistance, yet his fingernails were observed to be long and dirty, with a dark substance underneath, indicating neglect in nail care. Similarly, Resident #6, a female with moderately impaired cognition and similar health conditions, also required assistance with personal hygiene. Her care plan specified the need for staff assistance, but her fingernails were also found to be long and dirty, with a dark substance underneath. She reported that it had been more than four months since her nails were last cut, highlighting a significant lapse in care. Interviews with staff, including CNAs and the DON, revealed inconsistencies in the provision of nail care. While CNAs were responsible for cleaning and filing nails, they were not permitted to cut them, especially for diabetic residents. The DON acknowledged the lack of documentation for nail care and the potential risks of infection and injury due to inadequate nail maintenance. Despite an in-service training on nail care, the deficiency persisted, as evidenced by the residents' untrimmed and unclean nails.
Failure to Provide Adequate Foot Care for Diabetic Residents
Penalty
Summary
The facility failed to provide adequate foot care and treatment for two residents, both of whom had diabetes and impaired cognition, which placed them at risk of infection or mobility issues. Resident #3, a male with severely impaired cognition and multiple health issues including diabetes, had not had his toenails trimmed or cleaned, nor had a podiatry appointment been scheduled. His care plan required regular foot inspections, but observations revealed his toenails were yellow, jagged, thick, and broken, causing him pain. Similarly, Resident #6, a female with moderately impaired cognition and diabetes, had not received podiatry care for her thick toenails, despite a care plan that included weekly skin checks and podiatry care as needed. Interviews with residents and staff revealed that the facility had not arranged for podiatry visits since a change in ownership, and residents had not seen a podiatrist for several months. The Resident Council reported that they had not received nail care since the ownership change, and staff interviews confirmed that toenail care was not being provided. CNAs were responsible for fingernail care, but toenail care for diabetic residents was supposed to be handled by a podiatrist, who had not visited the facility for several months. The Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) acknowledged the lack of podiatry visits and the potential risks of infection and ingrown toenails due to inadequate nail care. The DON admitted to being unaware of who was responsible for scheduling podiatry visits and confirmed that no podiatry appointments had been made recently. The facility's Nail Care manual emphasized the importance of regular nail care to prevent infection and injury, particularly for residents with diabetes, but this protocol was not being followed.
Inaccurate MDS Assessment of Resident's Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding their history of falls. This deficiency was identified for one resident who had a documented history of falls, including incidents on two separate occasions. Despite these falls, the resident's quarterly MDS did not indicate any history of falls since admission or re-entry to the facility. This oversight was confirmed through interviews with family members, the resident's physician, and the MDS Coordinator, all of whom acknowledged the resident's fall history. The resident in question was an elderly male diagnosed with Alzheimer's Disease, muscle weakness, and lack of coordination, all of which contributed to his fall risk. The resident's care plan noted the potential for falls and included interventions such as fall risk screening and education for caregivers. However, the inaccurate MDS assessment failed to alert nursing staff to the resident's special care needs, potentially impacting the adequacy of care provided. The Director of Nursing (DON) admitted to overseeing the MDS process but was unaware of the specific procedures involved, further highlighting the gap in ensuring accurate assessments.
Failure to Implement Comprehensive Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of falls, specifically neglecting to include the use of a fall mat as per physician orders. The resident, an elderly male diagnosed with Alzheimer's Disease, muscle weakness, and lack of coordination, was identified as having a high risk for falls. Despite physician orders to place a fall mat due to this risk, the care plan did not reflect this intervention, leaving the resident vulnerable to potential falls. Interviews with family members revealed that they had not observed a fall mat placed next to the resident's bed during their visits, despite the resident's history of frequent falls. The Licensed Vocational Nurse (LVN) confirmed that the fall mat had not been included in the care plan, acknowledging that this oversight could lead to staff being unaware of the necessary intervention. The physician and Nurse Practitioner (NP) also noted the absence of the fall mat and emphasized the importance of including such interventions in the care plan to ensure resident safety. The MDS Coordinator and Director of Nursing (DON) both acknowledged that the fall mat should have been included in the care plan, as per the physician's order. The facility's Comprehensive Care Plan manual mandates the development of a person-centered care plan with measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case. This deficiency highlights a lapse in the facility's adherence to its own policies and procedures, potentially compromising the resident's safety.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #7, who was at high risk for falls due to Alzheimer's Disease, muscle weakness, and impaired mobility. Despite a physician's order to place a fall mat on the floor when the resident was in bed, this intervention was not implemented. Observations revealed that Resident #7 attempted to get out of bed without assistance, and no fall mat was present, increasing the risk of injury. Interviews with staff confirmed that the resident frequently tried to get out of bed without using the call light and required significant supervision. The lack of a fall mat, as ordered by the physician, was not included in the resident's care plan, contributing to the deficiency. The facility's preventive strategies to reduce fall risk were not adequately followed, as evidenced by the absence of a fall mat for Resident #7, who had a history of falls and was non-compliant with using a walker. Staff interviews indicated that the resident was moved closer to the nurse's station for better monitoring after a recent fall, yet the fall mat order was not executed. The facility's failure to implement the physician's order and update the care plan with necessary interventions for fall prevention led to the deficiency, as the resident's environment was not maintained free from accident hazards.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen and storage areas. During an inspection, it was noted that the facility did not maintain cleanliness in their refrigerators and freezers, with instances of moldy foods and unclean surfaces. Specifically, a pink stain of frozen liquid was found at the bottom of freezer #2, which was identified as strawberry drippings, posing a risk of cross-contamination. Additionally, moldy cucumbers and onions were discovered in freezer #3, which were not disposed of in a timely manner, increasing the risk of contamination. In the dry storage room, the facility improperly stored cleaning chemicals alongside food items, which could lead to chemical contamination. Eleven boxes of cleaning chemicals were found on the floor, and dry pinto beans were stored in an open, uncovered box. Furthermore, a plastic bag containing bottles of liquid caramel was leaking onto the floor, and a peanut butter container had food particles smeared on its exterior. These conditions could attract pests and lead to further contamination of food products. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding food storage and cleanliness. Staff acknowledged the risks associated with improper storage and contamination but cited issues such as the inability to access the shed for chemical storage and a lack of records for disposing of spoiled food. The facility's policies from 2012 were reviewed, highlighting the need for separate storage of chemicals and food, as well as proper cleaning schedules, but these were not effectively implemented, leading to the observed deficiencies.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the stove and freezer. During an observation and interview, it was noted that freezer #2 had significant condensation and ice buildup, with food particles and cardboard stuck in the ice. The Dietary Manager (DM) acknowledged the issue and reported it to the maintenance department using a QR code system, which was a new procedure for submitting work orders. However, the maintenance director did not have access to the system due to credential issues, and there was no documentation of the freezer issue prior to the survey. Additionally, the stove in the kitchen was found to be missing four out of eight knobs, which had been the case for at least two months. The DM admitted to keeping the knobs in his office to prevent loss and struggled to find replacements. There was no documentation or formal request for the stove repair, and the maintenance director claimed to have requested parts several times but did not provide evidence of these requests. The lack of proper stove knobs hindered the ability to regulate cooking temperatures, posing a risk of foodborne illnesses. Interviews with staff revealed awareness of the equipment issues, but there was a lack of formal communication and documentation regarding the necessary repairs. The maintenance director and staff were aware of the potential risks associated with the malfunctioning equipment, but the new QR code system and previous verbal communication methods led to delays in addressing the deficiencies. The facility's failure to maintain the kitchen equipment in safe operating condition could potentially compromise food safety and staff safety.
Deficiencies in Resident Accommodation and Call Light Accessibility
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation for their needs and preferences, particularly concerning the accessibility of call lights and room functionality. For Resident #7, the call light was observed to be out of reach under the bed, despite the resident's dependence on staff for mobility and a care plan that required the call light to be within reach. Resident #8's call light in the restroom lacked a cord, making it impossible for the resident to call for help if needed, which was a significant concern given her moderate cognitive impairment and frequent incontinence. Resident #51's call light was found attached to a privacy curtain, out of reach, which contradicted his care needs for supervision and assistance. Similarly, Resident #14, who had severe cognitive impairment and was at high risk for falls, had her call light on the floor, making it inaccessible. This was particularly concerning as she had a history of falls and required substantial assistance. The staff, including a medication aide and a CNA, acknowledged the improper placement of the call light and the associated risks. Additionally, Resident #65 experienced issues with her room door, which was difficult to open and close, potentially causing harm or inconvenience. This problem had persisted since her admission, and staff interviews revealed that the maintenance issue had not been promptly addressed. The facility lacked a specific policy on call lights, which contributed to the oversight in ensuring that residents could easily access assistance when needed.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to address their medical and nursing needs. Both residents had significant functional limitations in their range of motion, which were not addressed in their care plans. This oversight was identified during a review of the care plans and medical records of the residents, who were dependent on staff for activities of daily living and had severe impairments. Resident #59, who was unable to speak and had severely impaired vision, was dependent on staff for all activities of daily living. His medical conditions included traumatic brain dysfunction, tracheostomy, gastrostomy, muscle wasting, and atrophy. Despite these conditions, his care plan did not include interventions to address his limited range of motion or muscle atrophy. Although he had orders for occupational and physical therapy, these were not reflected in his care plan. Similarly, Resident #61, who was in a chronic vegetative state with a history of stroke and brain surgery, was also dependent on staff for all activities of daily living. His care plan failed to address his impaired range of motion, despite having orders for occupational and physical therapy. The Director of Rehabilitation and the Interim DON acknowledged that therapy services and interventions for range of motion should have been included in the care plans, but they were not. The facility lacked a restorative program, and CNAs were not providing passive range of motion exercises, increasing the risk of contractures and decreased mobility for the residents.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities to two residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being needs. Resident #51, a male with a history of weakness, pain, and falls, expressed that he preferred staying in his room due to leg pain and was not provided with materials for individual activities. His care plan indicated a need for such materials, but the facility did not fulfill this requirement, leaving him without activities to engage in. Similarly, Resident #65, a female with Alzheimer's dementia, anxiety, and depression, reported that she participated in group activities but had nothing to do afterward in her room. She expressed a preference for coloring, yet was not provided with the necessary materials. Observations and interviews with staff revealed a lack of clarity regarding responsibility for providing these materials, with conflicting statements from CNAs, the Activities Department, and the Interim DON. This oversight resulted in the residents experiencing boredom and a lack of engagement in their preferred activities.
Deficient Documentation of DNR Orders
Penalty
Summary
The facility failed to ensure that the medical records of five residents were complete and accurately documented in accordance with accepted professional standards and practices, specifically concerning their Texas Out-of-Hospital Do Not Resuscitate (OOH DNR) orders. This deficiency was identified during interviews and record reviews, which revealed that the OOH DNR forms for these residents were improperly completed, potentially affecting their validity. For Resident #57, the OOH DNR form was signed by a family member in the space reserved for the resident's legal guardian, agent, or proxy, without any indication of the family member's status as such. Similarly, Resident #61's OOH DNR form had the family member's signature in the incorrect section, and there was no documentation in the resident's electronic medical record to support the family member's authority as a legal guardian, agent, or proxy. Resident #59's OOH DNR form lacked dates for the declaration, witness signatures, and physician's signatures, raising concerns about its validity. Resident #65's OOH DNR form was signed and dated by a family member, but the family member's name was not printed, and the resident's date of birth was missing. For Resident #1, the family member signed in the space meant for a competent adult, without indicating their status as a legal guardian, agent, or proxy. The facility's policy on DNR orders did not specify the correct way to complete the OOH DNR form, contributing to these documentation errors.
Failure to Encourage Resident During Meals
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #26, received the necessary encouragement and assistance during meals as outlined in her care plan. Resident #26, who has Alzheimer's disease, anorexia, cognitive communication deficit, and unspecified dementia, was observed during a meal without receiving the required encouragement to eat. Despite her care plan specifying the need for frequent encouragement, staff did not offer a second choice or provide encouragement during the 24 minutes she had her lunch plate. The CNA and LVN involved acknowledged the lack of encouragement and the failure to offer a second choice, which could lead to potential weight loss and decline in ADL independence. Interviews with facility staff, including the Interim DON and the Administrator, revealed that it was expected for CNAs to encourage residents to eat multiple times during meals and to offer a second choice if a meal was refused. The facility's policy also required offering substitute food if a resident refused a menu item or ate less than 50% of the meal. Despite these expectations and training provided to CNAs, the staff did not adhere to these guidelines, resulting in the deficiency observed during the survey.
Neglect in Resident Nail Care Leads to Hygiene Deficiency
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good personal hygiene, specifically nail care. The deficiency was identified for a resident with a history of anemia, type 2 diabetes mellitus, Alzheimer's dementia, and hypertensive heart disease, who required substantial assistance with hygiene due to severe cognitive impairment. During an observation, the resident was seen eating with long fingernails that had brown particles underneath, indicating a lack of proper nail care. Interviews with staff, including an LVN, CNA, Interim DON, and the Administrator, revealed that CNAs were responsible for trimming fingernails, which was scheduled to be done on Sundays. However, the responsible CNA had not noticed the resident's long and dirty fingernails, and the charge nurses were expected to ensure that CNAs performed this task during their rounds. The facility's Nail Care policy emphasized the importance of regular nail management to prevent infection and injury, yet the policy was not effectively implemented in this case. The Interim DON and Administrator acknowledged the risk of infection and skin abrasion due to long fingernails and confirmed that CNAs received training on grooming upon hire and as needed. Despite these protocols, the resident's nail care was neglected, leading to the potential risk of cross-contamination and infection as the resident ate with untrimmed and dirty fingernails.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic drugs on a PRN basis for more than 14 days, which is a violation of their policy and standard practice. The resident, who was receiving Lorazepam for anxiety, had a PRN order that did not include a 14-day limit. This order was in place to address the resident's behavior of biting his lip. Despite the facility's policy requiring a 14-day stop date for PRN psychotropic medications, the order for Lorazepam was not appropriately limited, and the medication was administered on multiple occasions over several months without the necessary stop date. The interim DON acknowledged that the standard for PRN orders for psychotropic medications required a 14-day stop date to prevent unnecessary medication use and potential side effects. The facility's policy, revised in 2017, clearly stated that PRN orders for psychotropic drugs should be limited to 14 days unless a documented reason for extension is provided. However, this policy was not followed in the case of the resident, leading to the deficiency identified by the surveyors.
Infection Control Deficiencies in Incontinent Care and Oxygen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a CNA did not follow proper procedures during incontinent care for a resident with heart failure and muscle wasting. The CNA wiped from back to front, contrary to the expected front-to-back motion, potentially introducing germs from the rectal area to the vaginal area. This improper technique was observed during a care session and acknowledged by the CNA, who attributed the mistake to nervousness. In the second incident, another resident's oxygen nasal cannula was not stored properly when not in use. The resident, who was admitted with shortness of breath, had her oxygen tubing wrapped around the oxygen tank and the nasal cannula resting on her wheelchair. This improper storage was noted during an observation, and the resident confirmed that staff had left it in that position. The facility's policy requires that oxygen tubing and nasal cannulas be stored in a plastic bag to prevent contamination, which was not adhered to in this case. Interviews with facility staff, including the ADON, RNC, and Administrator, confirmed that the expected procedures were not followed in both cases. The staff acknowledged the potential for infection due to these lapses in protocol. The facility's policies on perineal care and oxygen administration emphasize the importance of proper techniques to prevent infections, which were not observed in these instances.
Failure to Suspend Driver After Allegation of Rough Handling
Penalty
Summary
The facility failed to implement its abuse prevention policy when it did not immediately suspend a Driver following an allegation of mistreatment by a resident. The incident involved a female resident who reported that the Driver was too rough with her while transferring her into a transportation van. Despite the resident's report, the Driver continued to work and transport another resident to a dialysis appointment before being suspended. This oversight could potentially place residents at risk of continued mistreatment and abuse. The resident involved in the incident was an elderly female with a history of diabetes mellitus type 2, kidney stones, chronic pain, restless leg syndrome, physical debility, and depression. Her cognitive status was assessed as intact, with a BIMS score of 10. The resident reported the incident to the facility staff, stating that the Driver had been rough with her, causing pain to her leg. However, subsequent assessments by nursing staff found no bruising, discoloration, or injuries, and the resident did not voice any pain during these assessments. Interviews with facility staff and other residents who were present during the outing did not corroborate the resident's allegations. The Driver denied the allegations and stated that the resident had not voiced any concerns during or after the transportation. The facility's policy on abuse and neglect requires immediate suspension of employees pending investigation of any allegations, but this was not followed, as the Driver continued to work after the allegation was reported. This failure to adhere to policy was acknowledged by the facility's administration, who noted that the Driver misunderstood the instructions given to her.
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 multiple issues including stained floors and ceilings, broken or missing floor tiles, non-functional restroom faucets, and light bulbs that were out. Additionally, there was a strong urine smell in B-Hall, trash on the floor in a living area, and a large hole in the wall under the medical records room/oxygen room. Hot water was not available in C-Hall, and Room B105 had wet urine and wet pieces of toilet paper scattered around, contributing to a strong urine smell and sticky floor. The medical records room and resident phone room both had holes in the walls, and D-Hall had broken floor tiles. These conditions were observed over multiple days and were confirmed through interviews with staff and record reviews, indicating ongoing issues that had not been addressed adequately by the facility's maintenance and housekeeping teams. Resident #3, a male with a history of falls, traumatic brain injury, and other significant medical conditions, was found to be living in unsanitary conditions. His room, B105, had a strong odor of urine, wet toilet paper on the floor, and a sticky floor. Despite efforts by the staff to clean the room, the urine smell persisted. Interviews with staff revealed that Resident #3 had a tendency to urinate on the floor, and housekeeping had been called multiple times to clean it up. However, the issue remained unresolved, contributing to the unsanitary conditions in the resident's room and the surrounding area. The facility's maintenance log and interviews with the Maintenance Director and DON revealed that there were ongoing issues with hot water availability in C-Hall and other areas. The circulating pump had been installed incorrectly by a previous Maintenance Director, leading to pipe eruptions and water leaks. Despite attempts to fix the issue, the problem persisted, and residents had to be taken to communal showers in A-Hall. The maintenance log also showed that several work orders for repairs and maintenance had not been addressed, further contributing to the unsafe and unsanitary conditions in the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident. The deficiency was identified when a resident reported that a dead roach had been inside the light fixture above his bed since he moved into the room in January 2024. Despite informing the staff about the issue, it had not been resolved. The resident also mentioned seeing roaches and pests entering through a restroom wall with a metal plate that had small open areas around it. During an interview, the housekeeping staff confirmed that resident hallways are cleaned daily, but only two housekeepers are responsible for cleaning two hallways each. The housekeeping staff admitted that they were unaware of the dead roach in the resident's light fixture and acknowledged that housekeeping is responsible for cleaning out the fixture. The facility's policy on deep cleaning, which includes cleaning lights and removing bugs, was not followed in this instance.
Failure to Implement Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident requiring cushion boots to prevent heel pressure ulcers. The resident, who was cognitively intact and diagnosed with multiple conditions including Diabetes Mellitus and Stage 4 pressure ulcers, did not have the use of cushion boots included in their care plan. Despite the Wound Care Nurse's education to the nursing staff and the resident about the necessity of cushion boots, the care plan did not reflect this requirement, and the resident repeatedly informed CNAs about the need for the boots without success. During observations and interviews, it was noted that the cushion boots were found on the dresser instead of being worn by the resident. The Wound Care Nurse confirmed that the absence of cushion boots could slow down the healing process or worsen the wounds. Multiple staff members, including CNAs and an LVN, acknowledged the importance of cushion boots for residents with pressure ulcers and the necessity of including them in the care plan to ensure proper care and prevent further injury. The Director of Nursing (DON) also confirmed that the cushion boots should have been included in the care plan for both the resident's well-being and for reimbursement purposes. The facility's Comprehensive Care Planning policy mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for Resident #1. The resident, who was cognitively intact and diagnosed with multiple conditions including Diabetes Mellitus and Stage 4 pressure ulcers, did not receive proper wound care for a facility-acquired pressure ulcer on the right outer heel. The care plan and physician orders specified the use of dressings and cushion boots to manage and prevent pressure ulcers, but these were not consistently applied or maintained by the staff. During an observation, the Wound Care Nurse was found to have not applied a dressing to Resident #1's right heel, leaving the wound exposed. The nurse also failed to date and initial the dressing, which is a critical step to ensure proper wound care tracking. Interviews with the Wound Care Nurse and other staff members revealed that there was a lack of communication and adherence to the care plan, as the resident repeatedly informed CNAs about the need for cushion boots, which were not consistently applied. The Wound Care Nurse acknowledged the importance of the dressing and cushion boots in preventing the wound from worsening but admitted to not having a marker to label the dressing. Further interviews with CNAs and the Director of Nursing (DON) confirmed that the facility's policy required dressings to be labeled with dates and initials to prevent infection and ensure timely wound care. The DON and other nursing staff also indicated that cushion boots, although considered a preventative measure, should be applied as per the care plan to prevent further pressure ulcers. The facility's policies on dressing changes and physician orders were not followed, leading to a risk of infection and deterioration of the resident's condition.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for two dumpsters located outside the facility. Observations on 04/11/2024 revealed that both dumpsters had their sliding doors open, and there was trash on the ground around them. Interviews with staff, including CNAs and the Maintenance Director, confirmed that the dumpsters were not being properly closed after use, and trash was not being picked up from the ground. Staff acknowledged the risks associated with these actions, including contamination, infection control issues, and attracting pests and rodents. The Maintenance Director admitted to being responsible for the trash around the dumpsters but cited being busy with other tasks as a reason for the oversight. The Director of Nursing (DON) also stated that it was everyone's responsibility to ensure the dumpster doors were closed and the area was kept clean. The DON highlighted the potential risks of not maintaining the dumpsters properly, such as attracting roaches, bugs, and stray animals, which could lead to infection control issues.
Infection Control Deficiency Involving Nasal Cannula
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an incident involving a resident's nasal cannula. The resident, a [AGE] year-old female with severe cognitive impairment, was observed lying in bed without her nasal cannula on. A Licensed Vocational Nurse (LVN) entered the room, noticed the nasal cannula on the floor, and placed it back on the resident's face without replacing it. This action was contrary to the facility's policy, which mandates changing tubing that becomes visibly contaminated. The LVN acknowledged the mistake and admitted there was no excuse for it. Interviews with other staff members, including Certified Nursing Assistants (CNAs) and another LVN, confirmed that the proper protocol for handling a nasal cannula found on the floor is to discard it and replace it with a new one to prevent infection. The facility's Oxygen Administration policy also supports this procedure. The failure to follow these guidelines placed the resident at risk for infection due to improper care practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pebble Creek Nursing Center | 0.4 mi | ★★★★★ | 10 | 0 |
| Vista Hills Health Care Center | 1.8 mi | ★★★★★ | 16 | 1 |
| Edgemere Estates | 3 mi | ★★★★★ | 4 | 0 |
| Center At Zaragoza, Llc | 3 mi | ★★★★★ | 3 | 0 |
| Ignite Medical Resort El Paso, Llc | 3.4 mi | ★★★★★ | 23 | 3 |
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