Epic Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Corsicana, Texas.
- Location
- 3210 W Hwy 22, Corsicana, Texas 75110
- CMS Provider Number
- 676295
- Inspections on file
- 45
- Latest survey
- October 3, 2025
- Citations (last 12 mo.)
- 12 (4 serious)
Citation history
Health deficiencies cited at Epic Nursing & Rehabilitation during CMS and state inspections, most recent first.
Multiple residents with severe cognitive impairment were involved in incidents of sexual activity and physical abuse that were not recognized or reported as abuse by staff. Staff failed to follow protocols for immediate reporting to the administrator, and interviews revealed confusion about what constitutes abuse and neglect, despite prior training.
Multiple incidents occurred in which two residents with dementia engaged in sexual activity and inappropriate behavior without timely recognition or reporting by staff, and a nonverbal resident was physically abused by a CNA in the presence of therapy staff. Staff failed to follow established protocols for identifying, documenting, and reporting abuse and neglect, particularly among residents with severe cognitive impairment.
Staff failed to immediately report incidents of alleged abuse, neglect, and exploitation, including sexual activity between two residents with dementia and the misappropriation of a resident's credit card by an employee. In each case, staff either delayed or failed to notify the Administrator as required, despite being aware of the facility's reporting policy.
A resident with severe cognitive impairment and a history of falls was able to leave the facility unsupervised when a visitor held the door open for a CNA, who did not recognize the resident as someone who should not exit. The resident was found outside by a passerby and returned without injury. The deficiency resulted from staff not recognizing the resident, lack of effective monitoring, and inadequate exit security.
The facility did not update or implement comprehensive care plans for three residents with dementia and other medical conditions after significant behavioral incidents and assessments. Incidents included inappropriate sexual behaviors between two residents and a lack of care plan interventions for routine monitoring after an elopement risk assessment. Care plans were not revised in a timely manner to address these needs, and communication lapses among staff contributed to the deficiencies.
A resident with severe cognitive impairment was found in bed with another resident, both fully clothed, in a room not assigned to either of them. The incident was documented by an LVN and reported to the DON, but the responsible party for the resident was not notified as required. Review of records and staff interviews confirmed that the required notification did not occur, despite facility policy and care plan interventions mandating such communication.
A resident with severe cognitive impairment and visual deficits had his credit card taken and used for personal expenses by the Business Office Manager, resulting in unauthorized withdrawals totaling $3,700. The card was stored in the business office during the resident's hospitalization, and the theft was discovered when the responsible party noticed the card missing. The BOM confessed to the misuse, and the incident was reported to administration after a delay. The facility's investigation confirmed the misappropriation.
A resident with multiple diagnoses, including dementia and Parkinson's disease, was admitted but did not receive a comprehensive MDS assessment within the required 14 days. The MDS Coordinator acknowledged the delay, attributing it to being behind on assessments and initially misclassifying the resident's status. The Administrator was unaware of the missed assessment, despite facility policy requiring timely completion.
The facility did not provide RN coverage for at least 8 consecutive hours per day, 7 days a week, as required. Staffing reports and staff interviews confirmed that no RNs were scheduled on multiple dates, and the DON's hours were incorrectly counted toward the RN coverage requirement despite a census above 60. Staff were unaware of the specific regulatory requirements, leading to a lack of RN services during the identified periods.
A significant number of residents did not receive their scheduled morning medications after a medication aide called in sick and the DON failed to notify facility staff, resulting in over 300 medication errors. The missed doses were not discovered until later in the morning, and the medical director instructed staff to monitor residents' vital signs rather than administer the missed medications. No adverse outcomes were reported at the time.
A resident with dementia and impaired decision-making was able to access and potentially ingest a cup containing a bleach and soap solution that was left unattended on a kitchen cart. Staff intervened and the resident was evaluated, with no toxic substances found. The incident occurred due to failure to prevent resident access to hazardous cleaning solutions.
The facility did not address moisture damage and discoloration in the ceiling of the secure unit hallway, where water stains and a black substance, suspected to be mold, were observed following an air conditioning leak. Staff interviews confirmed awareness of the issue, with concerns raised about the black substance and its potential health impact. The Maintenance Director delayed repairs pending policy requirements, resulting in a failure to maintain a clean and sanitary environment as required by facility policy.
The facility's kitchen failed to adhere to food safety standards, with an unclean ice machine, improperly sealed food packages, and uncovered desserts observed. Additionally, kitchen staff did not fully cover their hair, risking contamination. Interviews confirmed the importance of these practices to prevent contamination.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 8 days during a 6-month period. This deficiency was identified through staffing reports and interviews, revealing specific dates with no RN hours recorded. The DON acknowledged the issue and stated that managers, including herself, would cover when needed. The facility had concerns with weekend RN staffing and hired a weekend supervisor to address this.
A resident's nebulizer mouthpiece was improperly stored, not in a protective bag, which could lead to infection. Staff confirmed the need for proper storage, but facility policy lacked guidance on this matter.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene practices by staff members. A CNA did not change gloves or use hand sanitizer while providing incontinence care to a resident, and an LVN failed to perform proper hand hygiene while providing wound care to another resident. Both incidents involved handling clean items without changing gloves or sanitizing hands, increasing the risk of cross-contamination.
A facility failed to document the fluid intake for a resident with a fluid restriction order due to CHF. The resident, with moderate cognitive impairment, had a physician order for a fluid restriction of 1.5 liters per day, but the facility did not document the intake from December 17, 2024, to February 12, 2025. Staff interviews revealed awareness of the need for documentation, but it was not completed. The DON and interim ADM emphasized the importance of following physician orders, while the MD noted no major negative outcome due to other medical interventions.
A facility failed to submit a required five-day report to the state following an unwitnessed fall involving a resident with moderate cognitive impairment. The incident was not reported due to a communication breakdown between the DON and interim DON, potentially placing residents at risk for continued abuse or neglect.
The facility failed to provide scheduled showers to two residents, as documented in their EMRs. One resident, with moderately impaired cognition, missed multiple showers, resulting in poor personal hygiene. Another resident, with severe cognitive impairment, also missed several scheduled showers, although she appeared clean during observation. Staff interviews confirmed the lack of documentation and adherence to shower schedules.
A resident with Alzheimer's and severe cognitive impairment had a physician's order for a specific diet that was not reflected in their care plan. The MDS Coordinator, responsible for updating care plans, acknowledged the omission, which was expected to be entered promptly. The DON and Administrator emphasized the importance of updating care plans to ensure proper care.
Two residents with severe cognitive impairment eloped from the facility due to inadequate supervision and safety measures. One resident used chairs to climb over a fence, and both were found outside the facility. Staff interviews revealed lapses in supervision, as residents were left alone in the courtyard, contrary to policy.
A resident with moderate cognitive impairment was physically abused by an LVN during an altercation when the resident resisted being redirected from another room. The LVN allegedly hit the resident on the arm multiple times, as reported by a CNA. The incident was not immediately reported due to fear of retaliation, highlighting a failure in the facility's abuse prevention and reporting policies.
A resident with severe cognitive impairment in an LTC facility gave $300 to a CNA, who admitted to taking the money for personal use. The facility's administrator was informed and initiated an investigation, leading to the CNA's suspension. The facility has policies against misappropriation, but the incident occurred despite regular staff training.
A resident with cognitive impairment was allegedly hit by an LVN, but the incident was not reported within the required 24-hour timeframe due to fear of retaliation. The facility's policy mandates immediate reporting of abuse, which was not followed, potentially placing residents at risk.
A resident's quarterly MDS assessment failed to reflect an active dementia diagnosis, despite it being documented elsewhere in their medical records. The MDS Coordinator was unaware of the diagnosis, and the DON and ADM acknowledged the oversight, emphasizing the need for accurate assessments to ensure appropriate care.
A resident's medical record at a facility failed to include a diagnosis of dementia on the face sheet, despite other documents indicating this diagnosis. The omission was discovered during a review of the resident's records, which included a care plan and a physician recertification. Interviews with facility staff revealed confusion over responsibility for ensuring accurate documentation, and all acknowledged the importance of accurate records for appropriate care. The resident had multiple diagnoses and a BIMS score indicating moderate cognitive impairment, yet the Quarterly MDS assessment did not reflect any neurological diagnoses.
The facility failed to ensure that three residents received necessary grooming and personal hygiene services due to significant staffing issues. One resident with severe cognitive impairment was found in bed with a strong odor of urine and had not been cleaned or dressed despite requesting help. Another resident reported waiting up to an hour for staff to respond to call buttons and was often asked to use the bathroom in her brief. A third resident required substantial assistance with toileting and expressed frustration with agency staff unfamiliar with her care needs. Observations and interviews confirmed that the facility was not always fully staffed, leading to residents waiting long periods for care and experiencing diminished quality of life.
The facility failed to assess and schedule nursing staff based on the specific needs and acuity levels of residents, leading to prolonged wait times for care, residents being left soiled, and feelings of neglect. Staff reported being overwhelmed and unable to provide timely assistance, and observations confirmed strong odors of urine in multiple hallways.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment, including dementia and a BIMS score of 4, who was found engaging in sexual activity with a male resident, also diagnosed with dementia and other neurological conditions. Staff discovered both residents naked from the waist down and engaged in sexual activity. Prior to this, the same two residents were found lying in bed together, fully clothed, with the male resident's hand on the female resident's leg. In both cases, staff failed to recognize or report the incidents as abuse or neglect, despite being trained to do so, and did not immediately notify the administrator as required by facility policy. Another incident involved a nonverbal female resident with severe cognitive impairment and a history of aggressive behaviors. A CNA was observed by therapy staff forcefully grabbing and shaking the resident's wrist after the resident attempted to slap the CNA. The physical therapist intervened, and the resident became emotional and refused therapy, not returning to her baseline until the following day. The CNA denied shaking the resident's arm but was terminated following an investigation that confirmed physical abuse. Interviews with staff revealed a lack of understanding and inconsistent application of abuse and neglect reporting protocols. Several staff members, including CNAs and LVNs, admitted to not reporting incidents as abuse or neglect because they did not perceive the actions as malicious or because the residents involved were confused. The administrator was not notified of the incidents in a timely manner, and the facility's policies regarding immediate reporting and protection from abuse were not followed.
Failure to Prevent and Report Abuse and Neglect Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment and a male resident, both diagnosed with dementia, who were found engaging in sexual activity. Staff discovered the two residents in a state of undress and engaged in sexual behavior, but did not immediately recognize or report the incident as abuse or neglect. Staff interviews revealed a lack of understanding regarding the reporting requirements for abuse, particularly when both residents involved had cognitive impairments. The incident was not reported to the administrator until the following day, contrary to facility policy and staff training, which required immediate reporting of all abuse, neglect, or exploitation (ANE) incidents. Another incident involved the same male resident, who was found on a separate occasion lying in bed with the same female resident, fully clothed but with his hand on her leg. This event was also not reported as abuse or neglect, as staff did not perceive the behavior as malicious or inappropriate due to the residents' confusion and cognitive status. The lack of documentation and timely reporting of these events indicated a failure to follow established protocols for identifying and responding to potential abuse or neglect, especially among residents with dementia and impaired safety awareness. A third incident involved a nonverbal female resident with severe cognitive impairment who was physically abused by a CNA. The CNA forcefully grabbed and shook the resident's arm after being slapped by the resident, an action witnessed by therapy staff. The resident became emotional and refused further care, with her behavior not returning to baseline until the following day. The incident was reported to the administrator by the therapy staff, and the CNA was subsequently terminated. However, the social worker was not immediately informed, and the incident highlighted a breakdown in communication and adherence to abuse prevention policies among staff.
Removal Plan
- Resident 1 and Resident 2 were immediately separated from each other.
- Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker.
- The social worker performed trauma informed care assessment.
- Medical Director was notified, and orders obtained for psychiatric services.
- Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented.
- Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity.
- The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
- The resident's funds were replaced by the facility.
- All residents with behaviors documented as an incident report and/or in the progress notes will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors.
- If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately.
- Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart.
- Audits will be conducted for behavioral events.
- The Regional Business Office Director completed an audit for residents trust funds with no discrepancies noted.
- Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse.
- Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations.
- Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.
- Audits by the Regional Business Office Manager.
- Resident Fund Management Service will be audited.
- Education provided to all staff by the Administrator: Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
- Education to staff on Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
- Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
- All Facility staff will complete prior to working their next shift.
- New employees and agency staff will be educated upon hire and/or prior to working a shift.
- Knowledge will be verified via test and verbal discussion with affirmative feedback.
- Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
- Education provided to Nursing Staff by the Director of Nursing on Resident Kardex that will contain the updated care plans and interventions following behavioral events.
- Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing.
- Testing and verbal confirmation are utilized to assess knowledge retention.
- Annual training via Relias regarding resident's rights, theft, misappropriation and abuse.
- All Facility staff, new hire and agency will complete prior to working their next shift.
- Knowledge will be verified via test and verbal discussion with affirmative feedback.
- During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior.
- Will be reviewed during daily meeting and then weekly thereafter.
- Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.
- Medical Director informed of this plan at the Ad Hoc QAPI.
Failure to Immediately Report Alleged Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property were reported immediately to the Administrator as required. In multiple instances, staff did not recognize or report incidents of potential abuse or neglect within the mandated timeframes. For example, two residents with severe cognitive impairment and dementia were observed engaging in sexual activity on two separate occasions. Staff who witnessed or were informed of these incidents did not immediately report them to the Administrator, as required by facility policy and regulatory guidelines. Instead, the incidents were either not reported at all or were reported with significant delay, and some staff did not recognize the events as abuse or neglect due to the residents' cognitive status. Additionally, another incident involved the Business Office Manager confessing to the Marketing Director that she had taken a resident's credit card and used it for personal expenses totaling $3,700. The Marketing Director did not immediately report this confession to the Administrator, instead waiting until the following day. This delay in reporting was contrary to the facility's policy, which requires immediate notification of the Administrator and other authorities in cases of suspected exploitation or misappropriation of resident property. Interviews and record reviews confirmed that staff, including CNAs, LVNs, and administrative personnel, were aware of the requirement to report abuse, neglect, and exploitation immediately but failed to do so in these cases. The Administrator confirmed that she was not notified of the incidents in a timely manner and that staff were expected to follow the facility's reporting policy. These failures resulted in the facility being cited for not protecting residents from abuse, neglect, or exploitation by not ensuring timely reporting and investigation of alleged violations.
Removal Plan
- Resident 1 and Resident 2 were separated from each other.
- Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker.
- The social worker performed trauma informed care assessment.
- Medical Director was notified, and orders obtained for psychiatric services.
- Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented.
- Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity.
- The Business Office Manager was terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
- All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors.
- If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed.
- Audit of resident behaviors and interventions will be reviewed and noted in resident chart.
- Audits will be conducted for behavioral events.
- The Regional Business Office director completed an audit for residents' trust funds based on the immediate jeopardy.
- Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations.
- Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.
- Weekly audits by the Regional Business Office Manager.
- Weekly Resident Funds Management Service audits by the Regional Business Office Manager.
- If a discrepancy is found, it will be investigated by the regional business office manager, facility administrator, and Regional VP of Operations.
- Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
- Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
- Staff will be educated to separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
- All Facility staff will complete them prior to working their next shift.
- New employees and agency staff will be educated upon hire and/or prior to working a shift.
- Knowledge will be verified via test and verbal discussion with affirmative feedback.
- Staff that handle resident funds will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
- The resident will be monitored for aggressive/inappropriate behaviors.
- When no longer exhibiting aggressive/inappropriate behavior that warranted the 1:1 observation the Interdisciplinary Team and Physician will collaborate for the discontinuation of 1:1 observation.
- Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.
Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia and falls was able to elope from the facility. The resident, an elderly female with a BIMS score indicating severe cognitive impairment, was not identified as an elopement risk on her initial assessment, but her care plan did indicate a need for routine monitoring due to her cognitive status and risk for falls. On the day of the incident, the resident exited the facility when a visitor held the door open for a CNA entering the building. The CNA, who worked on the secured unit and was unfamiliar with the resident, did not recognize her as a resident because she was dressed in a way that resembled a visitor and was carrying a purse. The resident was found outside the facility by a passerby and was returned by a member of the public. Staff interviews revealed that the resident was not outside for more than five minutes and did not sustain any injuries. The incident was not immediately recognized by staff, and the CNA involved later acknowledged not recognizing the resident as someone who should not be leaving the building. The facility's security measures, including non-functioning cameras and lack of staff presence at the front door, contributed to the resident's ability to leave unnoticed. The facility's policies required the environment to be as free from accident hazards as possible and for residents to receive adequate supervision to prevent accidents, including unsafe wandering. However, the failure to recognize the resident as a resident, combined with the lack of effective monitoring and security at the exit, resulted in the resident's elopement. The incident was identified as Immediate Jeopardy, as it placed the resident at risk for harm.
Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents. For one resident with severe cognitive impairment and multiple medical diagnoses, the care plan was not updated after incidents involving being found in bed with another resident and a subsequent sexual activity incident. The only care plan in the electronic medical record focused on wandering and general safety, without addressing the new behavioral concerns or interventions related to these incidents. Another resident, also with dementia and additional medical conditions, exhibited inappropriate sexual behaviors on multiple occasions, including being found in bed with another resident and attempting to kiss others. Despite these documented behaviors, the care plan was not updated in a timely manner to include interventions addressing these behaviors. The care plan was only revised after several incidents had already occurred, and prior to that, there were no entries related to his sexual behaviors. A third resident, with severe cognitive impairment and a history of falls, had an initial elopement risk assessment completed that indicated the need for routine monitoring. However, the care plan did not include interventions for routine monitoring as required. Staff interviews revealed that communication lapses between agency nurses and the MDS coordinator contributed to the omission, and the care plan was not updated to reflect the necessary interventions following the assessment.
Failure to Notify Responsible Party of Change in Resident Status
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) of a resident following a significant change in the resident's status. Specifically, a female resident with severe cognitive impairment and multiple medical diagnoses, including dementia, was found lying in bed with a male resident in a room that did not belong to either of them. The male resident, who also had dementia and other neurological and medical conditions, was fully clothed and had his hand on the female resident's leg. The incident was documented by an LVN, who redirected the male resident and notified the Director of Nursing (DON), but did not recall notifying the responsible parties for either resident. Review of the female resident's records showed no documentation of the incident or notification to her RP on the date it occurred. The care plan for the female resident included interventions to ensure family and physician awareness of behaviors or changes, but there was no evidence these were followed in this instance. Similarly, the male resident's care plan, updated after the incident, included interventions for sexually inappropriate behavior and required family and physician notification of such behaviors, but there was no documentation that this occurred for the incident in question. Interviews with facility staff and the administrator confirmed that the incident was not reported to the responsible parties as required. The administrator stated she was unaware of the incident and expected immediate notification to both herself and the residents' RPs. The family member for the female resident reported only being notified of a later incident and expressed concern about not being informed of the earlier event. Facility policy requires notification of changes in condition or incidents affecting residents, but this was not followed in this case.
Failure to Prevent Staff Misappropriation of Resident Funds
Penalty
Summary
A facility failed to protect a resident from exploitation and misappropriation of property when the Business Office Manager (BOM) took the resident's net spend credit card and used it for personal expenses, withdrawing a total of $3,700. The resident, who had severe cognitive impairment as indicated by a BIMS score of 0 and was care planned for visual impairment and secure storage of personal items, had his wallet stored in the business office while he was hospitalized. Upon the resident's return, his responsible party (RP) noticed the credit card was missing from the wallet, which was being held by the BOM. The BOM confessed to the Marketing Director that she had taken and used the resident's credit card for personal use, initially stating she used $2,000, then $3,000, and admitted she could not return the money. The Marketing Director did not immediately report the confession to the Administrator (ADM), instead waiting until the following morning. The incident was subsequently reported to the ADM, and the police were contacted, but no charges were pressed as the resident received the money back. Interviews with staff, including the Social Worker (SW) and interim Director of Nursing (DON), revealed they were not aware of the incident until after it occurred. The facility's investigation confirmed the misappropriation, and the BOM was terminated. The facility's policy required protection of residents from exploitation and misappropriation by anyone, including staff, and outlined the need for protocols to prevent and identify theft or exploitation. The failure to prevent the BOM from accessing and using the resident's credit card constituted a violation of these policies.
Failure to Complete Timely Comprehensive Assessment for New Admission
Penalty
Summary
The facility failed to conduct an initial comprehensive, accurate, and standardized assessment of a newly admitted resident's functional capacity within the required 14-day timeframe. Specifically, a male resident with diagnoses including dementia, Parkinson's disease, hypotension, anxiety disorder, and benign prostatic hyperplasia was admitted, but no Minimum Data Set (MDS) assessment was completed within the mandated period. Review of the electronic medical record confirmed the absence of the MDS assessment, and the MDS Coordinator acknowledged that the assessment was not completed on time, citing being behind on assessments and initially misclassifying the resident as respite due to his hospice status. Further interviews revealed that the Administrator was unaware of the overdue MDS assessments and that the MDS Coordinator, who was responsible for timely completion, reported both to regional MDS staff and directly to the Administrator at the local level. Facility policy requires comprehensive assessments to be completed within 14 days of admission, in accordance with the Resident Assessment Instrument (RAI) User Manual. The failure to complete the assessment as required resulted in the resident not having their care and treatment needs fully assessed within the appropriate timeframe.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required services of a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as mandated. Observations and record reviews revealed that there was no RN coverage on multiple dates, specifically from 8/11 to 8/15, 8/18 to 8/22, 8/25 to 8/28, and on 9/1 and 9/2. The Daily Nurse Staffing Reports and interviews with staff confirmed that there were zero scheduled RN hours on these dates, despite the facility having a census of 72 residents. The Director of Nursing (DON) and other staff members were unaware that the DON's hours could not be used to fulfill the RN staffing requirement when the average daily census exceeded 60 residents. The facility did not have any other RNs scheduled to cover the required hours during the identified periods, and the RN who typically provided coverage was out on leave and not replaced. Interviews with the DON, staffing coordinator, and administrator revealed a lack of understanding regarding the RN coverage requirements, particularly that the DON's hours could not be counted toward the mandated RN coverage when the census was above 60. The facility's own policy stated that a RN must provide services at least eight hours every 24 hours, seven days a week, and that the DON may only serve as charge nurse if the average daily occupancy is 60 or fewer residents. Despite this, the facility relied solely on the DON's hours and did not ensure additional RN coverage, resulting in noncompliance with federal staffing requirements.
Failure to Administer Scheduled Medications Due to Staff Absence
Penalty
Summary
The facility failed to provide pharmaceutical services by not administering morning medications to 35 out of 72 residents on a specific date, resulting in 305 medication errors. The missed medication administration was due to a medication aide (MA) calling in sick after the shift had started and not coming to work. The MA notified the DON via text message early in the morning, but the DON did not inform anyone at the facility that the MA would not be present. As a result, no arrangements were made to cover the medication pass for the affected halls. Multiple staff interviews confirmed that the absence of the MA went unnoticed until late in the morning, at which point another MA was called in to pass medications. By then, the morning medication pass for two halls had been entirely missed. Nurses and other staff became aware of the situation only after residents had not received their scheduled medications. The medical director was notified and gave orders not to administer the missed medications but to monitor residents' vital signs for 12 hours and report any changes in condition. The incident was documented as medication errors for all affected residents. Resident records and staff interviews indicated that the residents involved had various significant medical diagnoses, including cerebral infarction, dementia, schizoaffective disorder, Huntington's disease, atrial fibrillation, and cancer. Progress notes and interviews confirmed that vital signs were monitored and no adverse outcomes were observed or reported at the time. The facility's own policy required medications to be administered in a safe and timely manner, with staffing schedules arranged to prevent interruptions, but these procedures were not followed in this instance.
Resident Accessed Bleach Solution Due to Inadequate Hazard Control
Penalty
Summary
A deficiency occurred when a resident with diagnoses including anxiety disorder, unspecified dementia, schizophrenia, and cognitive communication deficit was able to access and potentially ingest a cup containing a bleach and soap solution. The resident, who was dependent in several activities of daily living and had impaired decision-making abilities, was observed by kitchen staff with a cup that had been used to soak dishes in a diluted bleach solution. The staff member immediately intervened and notified nursing staff. The resident was assessed, found to be alert and oriented, and was subsequently sent to the emergency room for evaluation, where no toxic substances were detected and all laboratory results were normal. Interviews with staff revealed that the cup containing the bleach solution was left accessible on a cart in the kitchen doorway, allowing the resident to obtain it. The facility's policy on safety and supervision was reviewed, which emphasizes both a facility-oriented and individualized approach to resident safety. The incident demonstrated a failure to ensure that hazardous cleaning solutions were not accessible to residents, particularly those with cognitive impairments and a history of impaired decision-making.
Failure to Address Ceiling Damage and Suspected Mold in Secure Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of five halls reviewed, specifically in the secure unit hallway. Observations revealed water stains and a black substance on the ceiling, which staff members identified as resulting from a previous air conditioning leak. The black substance was described by both the LVN and DON as appearing to be mold. The Maintenance Director acknowledged awareness of the water stains but stated he had not been notified about the black substance. He indicated that the air conditioning leak had been repaired weeks prior and was waiting for the ceiling to dry before proceeding with repairs, as required by facility policy to obtain three estimates before work could begin. Interviews with staff confirmed that the issue had persisted for some time, with the LVN and DON both expressing concern about the presence of the black substance and its potential to be mold. The DON and Maintenance Director both stated that the black substance could cause respiratory issues for residents and staff if it was indeed mold. The facility's Homelike Environment policy requires a clean, sanitary, and orderly environment, which was not met in this instance due to the unresolved ceiling damage and possible mold presence.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food service safety standards in its main kitchen, as observed during a survey. The ice machine in the tray-serving area was found to have dried white drip stains, brownish and white build-up, and black build-up on various parts, indicating it had not been cleaned as required. Additionally, several opened packages of food in the dry goods pantry, including powdered milk, elbow macaroni pasta, cornmeal, long grain rice, breadcrumbs, and instant potatoes, were not securely closed after opening, which could lead to contamination. On a subsequent observation, an uncovered container of diced peaches and 12 dessert cups containing fruit salad were found on a cart and preparation space in the kitchen, respectively. These items were uncovered while being prepared for meal distribution, increasing the risk of cross-contamination. Furthermore, during meal plating and serving, it was noted that the cook's hair was not fully covered, and the dietary aide's hair was partially uncovered due to wearing a warm cap over the hairnet, which could result in hair contaminating the food. Interviews with the dietary aide and manager confirmed the importance of covering food and hair to prevent contamination. The dietary aide acknowledged the oversight in not covering the desserts and the container of peaches, while the dietary manager emphasized the need for securely closing food packages to prevent contamination and attract pests. The facility's policies on ice machine maintenance and food storage were reviewed, highlighting the need for adherence to safe food handling practices.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 8 days during the 6-month review period. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have the required RN coverage on specific dates between April and June 2024. The absence of RN coverage was confirmed by reviewing CMS PBJ staffing reports, which showed no RN hours recorded on eight specific dates. During interviews, the Director of Nursing (DON) acknowledged the lack of RN coverage and stated that managers, including herself, would come in when there was no licensed nurse available. The DON, who is on salary, mentioned that her weekend work was not reflected in the payroll system but was documented on a paper form. The facility had concerns with RN staffing on weekends and had since hired a weekend supervisor who is an RN. The Interim Administrator also confirmed awareness of the RN coverage lapse and stated that the DON was expected to cover when needed. The facility's policy requires RN services for at least 8 consecutive hours a day, 7 days a week, which was not met during the specified period.
Improper Storage of Nebulizer Mouthpiece
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, specifically in the storage of a nebulizer mouthpiece. The resident, a cognitively intact male with a history of influenza and acute cough, was observed to have his nebulizer mouthpiece improperly stored on a bag of chips and on top of the nebulizer, rather than in a protective bag. This improper storage was noted during observations and interviews on two separate occasions, indicating a lapse in following professional standards of practice and the resident's comprehensive care plan. Interviews with facility staff, including an LVN and the ADON, confirmed that the mouthpiece should have been stored in a bag when not in use to prevent contamination and infection. The facility's policy on oxygen administration did not provide guidance on the storage of respiratory items, contributing to the oversight. This deficiency in care could potentially place the resident at risk for respiratory infection due to the lack of adherence to proper storage protocols.
Infection Control Deficiencies Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two separate incidents involving improper hand hygiene practices by staff members. In the first incident, a Certified Nursing Assistant (CNA) did not change gloves or use hand sanitizer while providing incontinence care to a resident. The CNA was observed cleaning the resident and handling clean briefs without changing gloves or sanitizing hands, which could lead to cross-contamination. The CNA acknowledged the lapse in protocol, admitting to forgetting her hand sanitizer and recognizing the importance of hand hygiene in preventing the spread of germs. In the second incident, a Licensed Vocational Nurse (LVN) failed to perform proper hand hygiene while providing wound care to another resident. The LVN was observed changing dressings on the resident's feet without washing hands or using hand sanitizer between glove changes. Additionally, the LVN used a gloved finger to apply ointment directly to the wound, which was against the facility's policy. The LVN also improperly handled a bottle of normal saline, which was used in multiple rooms, increasing the risk of contamination. Both incidents highlight a failure to adhere to the facility's hand hygiene policy, which requires handwashing or the use of hand sanitizer before and after resident contact, after glove removal, and when moving from a soiled to a clean body site. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the importance of these protocols in preventing cross-contamination and infection, emphasizing the need for staff to follow proper procedures consistently.
Failure to Document Fluid Intake for Resident with CHF
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not document the fluid intake for a resident with a fluid restriction order due to congestive heart failure (CHF). The resident, who had moderate cognitive impairment and was dependent on assistance for daily activities, had a physician order for a fluid restriction of 1.5 liters per day. However, the facility did not document the resident's fluid intake from December 17, 2024, to February 12, 2025. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) was aware of the need to document the resident's fluid intake but did not know why it had not been done prior to February 12, 2025. The Director of Nursing (DON) and the interim Administrator (ADM) both stated that physician orders should always be followed and emphasized the importance of documenting fluid intake for residents with CHF to prevent potential negative outcomes such as weight gain. The Medical Doctor (MD) also expected the facility to follow the physician order, although he noted that there would not be any major negative outcome due to the resident receiving diuretic medication and attending cardiology appointments.
Failure to Report Investigation Results of Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report the results of an alleged abuse and neglect incident involving a resident who experienced an unwitnessed fall. The incident occurred on January 27, 2025, and the facility was required to submit a five-day report to the state by February 1, 2025. However, the report was not submitted, which could potentially place residents at risk for continued abuse or neglect without appropriate corrective actions being taken. The resident involved was an elderly female with diagnoses including primary generalized osteoarthritis, dysphagia, and primary hypertension, and had moderate cognitive impairment as indicated by a BIMS score of ten. Interviews with the Director of Nursing (DON) and the interim DON revealed a communication breakdown regarding the responsibility for submitting the report. The interim DON acknowledged that the report was completed but not sent to the state due to a misunderstanding about who was responsible for its submission.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received necessary services to maintain personal hygiene. Specifically, two residents did not receive showers according to their scheduled times, as documented in their electronic medical records (EMR). This deficiency was observed through a review of the residents' care plans, general orders, and bathing tasks, which showed multiple instances where showers were not provided or documented. Resident #1, a female with moderately impaired cognition and various medical conditions, was scheduled to receive showers on Mondays, Wednesdays, and Fridays. However, from December 2, 2024, to January 13, 2025, there were numerous occasions where showers were not documented as having occurred. Observations on January 14, 2025, revealed that Resident #1 had poor personal hygiene, including facial hair and a foul odor from her feet, indicating a lack of proper bathing care. Resident #2, a female with severe cognitive impairment and other medical diagnoses, was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Similar to Resident #1, her EMR reflected multiple missed showers during the same period. Although she appeared clean during an observation on January 14, 2025, the lack of documentation and adherence to her shower schedule was evident. Interviews with facility staff confirmed the failure to document and provide showers as required by the residents' care plans and facility policies.
Failure to Update Resident's Care Plan with Dietary Orders
Penalty
Summary
The facility failed to ensure that a comprehensive care plan accurately reflected the dietary needs of a resident diagnosed with Alzheimer's disease and mild protein-calorie malnutrition. The resident, who had severe cognitive impairment, was prescribed a diet of regular, pureed, and nectar thick liquids by their physician. However, the care plan dated two days after the physician's order did not include these dietary instructions, indicating a lapse in updating the care plan to reflect the resident's current needs. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the MDS Coordinator was responsible for updating care plans when there were changes in condition or orders. The MDS Coordinator acknowledged the omission, suggesting it might have been mistakenly deleted, and emphasized the importance of entering orders promptly to ensure proper care. The Administrator confirmed the expectation that care plans be updated with new orders to meet residents' medical needs, highlighting the risk of improper care if updates are not made.
Elopement Incidents Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for two residents, leading to their elopement. Resident #1, a male with severe cognitive impairment and a history of dementia, was identified as a risk for elopement. Despite this, he managed to leave the facility unsupervised. His care plan included risks for wandering and injury, but these measures were insufficient to prevent his elopement. Similarly, Resident #2, also with severe cognitive impairment and diagnosed with vascular dementia, eloped from the facility. He was able to climb over a fence using chairs, indicating a lack of adequate supervision and environmental safety measures. Interviews with staff revealed that Resident #2 was left alone in the courtyard, which was against the facility's policy, and he was found in a nearby hospital parking lot by a staff member. The facility's policy on safety and supervision was not effectively implemented, as evidenced by the elopement incidents. Both residents used objects to overcome physical barriers, highlighting the inadequacy of the facility's preventive measures. The staff interviews confirmed that the residents were at risk of serious harm due to these lapses in supervision and environmental safety.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical and verbal abuse, as evidenced by an incident involving a resident who was physically abused by a Licensed Vocational Nurse (LVN). The incident occurred when the resident, who has moderate cognitive impairment and physical limitations, was being redirected from another resident's room. During this process, the resident reportedly became upset and began to resist, leading to an altercation with the LVN. According to interviews and records, the LVN allegedly hit the resident on the right arm multiple times after the resident attempted to grab and bite the LVN. This account was corroborated by one Certified Nursing Assistant (CNA), while another CNA did not witness the LVN hitting the resident. The resident later reported the incident to another staff member, expressing that she felt safe in the facility and had no other concerns. The facility's policies on abuse prevention and reporting were not effectively implemented, as the incident was not immediately reported by the staff involved. The delay in reporting was attributed to fear of retaliation. The facility's policy mandates that any suspected abuse should be promptly reported to management to ensure the safety and well-being of residents.
Misappropriation of Resident's Money by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation and exploitation of property by allowing a Certified Nursing Assistant (CNA) to take money from the resident for personal use. The resident, who had severe cognitive impairment and was fully dependent on staff for daily activities, reported giving $300 to the CNA, who admitted to receiving the money. The resident expressed no concern about getting the money back, stating he felt safe in the facility and had plenty of money. The facility's administrator was informed of the incident by another CNA and immediately began an investigation. The CNA involved admitted to taking the money despite being trained on the facility's policy against misappropriation of property. The administrator suspended the CNA and planned to terminate her employment. Interviews with the Director of Nursing (DON) and the administrator revealed that staff were regularly in-serviced on abuse and reporting procedures, and the facility had policies in place to prevent such incidents. The facility's policies on abuse prevention and reporting emphasize the responsibility of all employees and associated individuals to report any incidents of neglect, abuse, or misappropriation of resident property. The policies define misappropriation as the wrongful use of a resident's belongings or money without consent and outline procedures for preventing and addressing such incidents. Despite these policies, the incident occurred, highlighting a lapse in adherence to the established protocols.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident with moderate cognitive impairment and multiple medical conditions, including spastic hemiplegia and dysphagia. The incident involved a Licensed Vocational Nurse (LVN) allegedly hitting the resident on the arm during an attempt to redirect her from another resident's room. The incident was reported by a Certified Nursing Assistant (CNA) to the Director of Nursing (DON) the following day, exceeding the 24-hour reporting requirement. Interviews revealed that the CNA who witnessed the incident delayed reporting due to fear of retaliation from the LVN. The CNA eventually reported the incident to the DON when contacted for a shift the next day. The DON then informed the Administrator, who is also the Abuse Coordinator, and initiated an investigation. The facility's policy mandates immediate reporting of suspected abuse to management, which was not adhered to in this case. The investigation included interviews with staff members present during the incident. Conflicting accounts were given, with one CNA confirming the LVN hit the resident, while another did not witness the alleged abuse. The LVN denied hitting the resident, stating she only blocked the resident's attempts to hit her. The facility's policy on reporting abuse emphasizes the importance of immediate reporting to prevent further harm, which was not followed, potentially placing residents at risk.
Inaccurate MDS Assessment for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's active diagnosis of dementia. This deficiency was identified during a review of the resident's records, which showed that the MDS did not include the dementia diagnosis, despite it being documented in other parts of the resident's medical records, such as the care plan and physician recertification. The MDS Coordinator, who was responsible for completing the MDS, was unaware of the dementia diagnosis and stated that the diagnosis information was carried over from previous assessments. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged the oversight and emphasized the importance of accurate MDS assessments for appropriate resident care. The resident in question was a male with multiple diagnoses, including malignant neoplasm of the prostate, type 2 diabetes mellitus with proliferative diabetic retinopathy, schizoaffective disorder, major depressive disorder, muscle wasting and atrophy, and post-traumatic stress disorder. The resident's Brief Interview for Mental Status (BIMS) score indicated moderate impairment, yet the MDS did not reflect any neurological diagnoses. Interviews with facility staff revealed that the MDS Coordinator and the DON were responsible for ensuring the accuracy of MDS assessments, and the ADM expected all assessments to be completed accurately. The facility's policy required comprehensive assessments to be consistent with progress notes, care plans, and resident observations.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically omitting the diagnosis of dementia from the resident's face sheet. This oversight was identified during a review of the resident's medical records, which included a face sheet, a Quarterly Comprehensive MDS assessment, and a care plan. The face sheet, dated July 18, 2024, did not list dementia as a diagnosis, despite other documents, such as the care plan and a physician recertification, indicating the resident had been diagnosed with dementia. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed that there was a lack of clarity regarding who was responsible for ensuring the accuracy of the face sheet, and all acknowledged the importance of accurate documentation for providing appropriate care. The resident in question was a male with multiple diagnoses, including malignant neoplasm of the prostate, type 2 diabetes mellitus with proliferative diabetic retinopathy, schizoaffective disorder, major depressive disorder, muscle wasting and atrophy, and PTSD. The resident's BIMS score indicated moderate cognitive impairment, yet the Quarterly MDS assessment did not reflect any neurological diagnoses. The facility's policy on charting and documentation emphasized the need for complete and accurate records to facilitate communication among the interdisciplinary team. The failure to include dementia in the resident's face sheet could lead to inadequate care due to inaccurate assessments, as acknowledged by the facility's staff during interviews.
Failure to Provide Adequate ADL Care Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that three residents received the necessary services to maintain grooming and personal hygiene. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs), was found in bed with a strong odor of urine, no sheets, and had not been cleaned or dressed despite requesting help all morning. Resident #2, who had no cognitive impairment but required moderate assistance with personal hygiene, reported waiting up to an hour for staff to respond to call buttons and was often asked to use the bathroom in her brief, leading to feelings of neglect and indignity. Resident #3, who required substantial assistance with toileting and had limited use of her right arm, also reported long wait times for staff assistance and expressed frustration with agency staff who were unfamiliar with her care needs. Observations and interviews revealed that the facility had significant staffing issues, with regular staff not showing up and agency staff being overloaded. The facility's staffing coordinator and other staff members confirmed that the facility was not always fully staffed and that the staffing levels were determined by a formula based on the facility budget and resident census, without considering the acuity of residents' care needs. This led to residents waiting long periods for care, feeling neglected, and experiencing diminished quality of life. The facility's policy stated that adequate staffing should be maintained to meet residents' needs, but interviews with staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the staffing levels were not adjusted based on the residents' health conditions or care requirements. This resulted in residents being left soiled or wet for prolonged periods, strong odors of urine in the hallways, and residents feeling unimportant and frustrated due to the lack of timely care.
Inadequate Staffing Based on Resident Needs
Penalty
Summary
The facility failed to assess the care required by the resident population, considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts when determining staffing requirements. This failure was evident in the cases of three residents who required varying levels of assistance and care. For instance, one resident with severe cognitive impairment and paraplegia was dependent on staff for all activities of daily living (ADLs) and was often left unattended and soiled for prolonged periods. Another resident with Huntington's Disease and muscle wasting required partial assistance but reported long wait times for care and being asked to use the bathroom in her brief, leading to feelings of neglect and indignity. A third resident with atrial fibrillation and cerebral infarction required substantial assistance and expressed concerns about the competency of agency staff in using her stand-up lift, leading to reluctance in asking for help and extended wait times for care. The facility's staffing decisions were based on a predetermined formula that considered the facility budget and current resident census but did not account for the specific needs and acuity levels of the residents. Interviews with staff, including CNAs, LVNs, and the DON, revealed that the staffing levels were often inadequate to meet the residents' needs, leading to rushed and impersonal care. Staff reported feeling overwhelmed and unable to provide timely assistance, resulting in residents waiting for extended periods for basic care needs such as toileting and hygiene. Observations confirmed strong odors of urine in multiple hallways and residents left unengaged and unattended. Complaints made to the state on behalf of the residents highlighted issues with staffing shortages, residents being left soiled, and the facility having a strong odor of urine. Interviews with residents corroborated these complaints, with reports of long wait times for care, feelings of neglect, and being asked to use the bathroom in their briefs. The facility's reliance on agency staff to fill gaps further exacerbated the issue, as these staff members were often unfamiliar with the residents' specific care needs. The facility's policy on staffing, dated April 2007, stated that adequate staffing would be maintained to meet residents' needs, but the current practices did not align with this policy, leading to unmet needs and compromised resident care.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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