Five Points At Lake Highlands Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 9009 White Rock Tr, Dallas, Texas 75238
- CMS Provider Number
- 455895
- Inspections on file
- 43
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 12 (3 serious)
Citation history
Health deficiencies cited at Five Points At Lake Highlands Nursing And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, identified as high risk for elopement, was able to exit the secured unit by forcing open a window that lacked an alarm and had a compromised locking mechanism. Staff last observed the resident in a common area, but during routine care activities, the resident left undetected. The resident was later found by emergency services with injuries, including a compression fracture, highlighting a failure in supervision and environmental safety measures.
A resident with Alzheimer's disease, who was on anticoagulant therapy, was accidentally hit by a door opened by an LVN. The LVN did not document the incident, complete an incident report, or notify the resident's representative or physician about the event or the resident's broken dentures. The family discovered bruises and the broken dentures upon discharge and reported not being informed of these issues. Staff interviews confirmed the lack of required notification and documentation.
A resident's room was found to have multiple extension cords running across the floor and exposed wires on a bed adjuster, creating tripping and electrical hazards. The resident required substantial assistance with ADLs and was at risk for falls. Facility staff acknowledged these hazards during interviews, and the facility's policy requires a safe and dignified environment.
A resident who required total assistance for ADLs due to reduced mobility did not receive scheduled showers for over five weeks, with records showing only sporadic bed baths and one shower after the resident complained. Staff interviews revealed inconsistent CNA assignments and a lack of oversight in ensuring showers were provided and documented, despite facility policy and the resident's care plan requiring regular bathing.
A resident admitted for respite care while on hospice did not receive scheduled hospice aide services due to the facility's failure to obtain required hospice documentation and lack of coordination with the hospice agency. Staff were unclear about the hospice plan of care and did not designate a team member to coordinate with hospice representatives, resulting in missed services during the resident's stay.
A resident with cognitive impairment and mental health diagnoses was left without a privacy curtain in her shared room for several weeks, requiring her to use the bathroom to change clothes due to lack of privacy. Staff interviews confirmed awareness of the missing curtain, but no action had been taken to restore it, resulting in a failure to maintain the resident's dignity as required by facility policy.
A resident with severe cognitive impairment and multiple medical conditions, who required maximum assistance with personal hygiene, was found with overgrown and dirty fingernails. Staff interviews confirmed that both CNAs and nurses were responsible for nail care, and facility policy required regular nail management, but the resident's nails had not been cleaned or trimmed as needed.
A CMA failed to disinfect a blood pressure cuff between use on two residents during a medication pass, contrary to facility infection control policy. Staff interviews confirmed that equipment should be sanitized between each resident, and the facility's policy requires cleaning of non-invasive equipment between uses to prevent cross-contamination.
A resident with multiple medical and behavioral health conditions was discharged without adequate preparation or documentation to a setting that could not meet her needs. The facility did not ensure the discharge destination was appropriate, failed to provide necessary referrals or ombudsman information, and did not document the representative's refusal of alternate placement, resulting in the resident being placed in an unsafe environment and ultimately requiring intervention by authorities.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A medication cart was found unlocked and unattended, with various medications accessible while a resident was present in the hallway. The medication technician responsible for the cart was not in direct proximity, contrary to facility policy requiring medication carts to be locked and attended by authorized staff.
A resident with significant respiratory needs was found in a room with a missing air conditioning vent cover, visible black substance in the ceiling opening, and a broken built-in dresser with missing drawers and doors. The room was warm with poor air circulation, and the resident reported difficulty sleeping and breathing due to the heat. Staff interviews confirmed the environmental issues and lack of timely repairs.
A resident with multiple medical conditions and a high risk for falls did not have a floor mat in place as required by his care plan while in bed. Staff interviews revealed the mat was removed for cleaning or to prevent tripping, and the assigned CNA was unaware of the intervention due to unfamiliarity with the resident's care plan. This resulted in the facility not following the specified fall prevention measures.
A resident with hemiplegia and hemiparesis who required staff assistance for bathing did not receive scheduled showers, and there was missing documentation for several shower days. The resident reported not being bathed for a week and expressed discomfort, while staff interviews confirmed the importance of documentation and monitoring, but records were incomplete.
The facility did not consistently perform daily inventory checks on an emergency response cart, resulting in incomplete documentation and unchecked critical items such as a backboard and medical supplies. Staff interviews confirmed lapses in the required nightly checks, and the facility lacked a policy for CPR, potentially impacting emergency response readiness.
A resident with severe cognitive impairment and a history of falls sustained multiple bruises and a laceration, which were not reported or investigated by the facility staff as required by policy. Despite several staff members noticing the injuries, they failed to notify the abuse and neglect coordinator, leading to a deficiency in care standards.
A facility failed to document blood pressure monitoring for a resident before administering Propranolol, as required by physician orders. The resident, with a history of hypertension and other conditions, received the medication without consistent blood pressure checks, risking inappropriate dosing. Staff interviews revealed a lack of documentation and communication, with the MAR lacking a section for recording blood pressure readings.
The facility failed to complete necessary PASARR Level 2 evaluations for several residents with mental illness, potentially risking their access to specialized services. Despite having serious mental health diagnoses, some residents were not properly assessed, and staff were unaware of these oversights. The facility's policy on PASARR maintenance was not followed, leading to deficiencies in resident care.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene by a CNA during incontinence care and the lack of enhanced barrier precautions for two residents with wounds and indwelling medical devices. These deficiencies increased the risk of infection transmission.
The facility failed to store, prepare, distribute, and serve food according to professional standards, as observed during a kitchen survey. Expired and unsealed food items were found in the dry storage, refrigerator, and freezer areas, posing a risk of cross-contamination and airborne illnesses to residents. Despite staff training, these deficiencies indicate a lack of adherence to food safety protocols.
A facility failed to maintain a safe and homelike environment for a resident with severe cognitive impairment and multiple medical conditions, as evidenced by a broken windowsill in her room that was not repaired in a timely manner. Despite the presence of a maintenance log system, the issue was not addressed until the resident and her roommate were moved to another room for repairs. Staff interviews revealed a lack of awareness and urgency in addressing the deficiency, highlighting a failure to adhere to the facility's policy on maintaining a safe and comfortable environment.
A resident with severe cognitive impairment and incontinence was not provided thorough incontinence care, leaving her at risk for infection. The CNA initially failed to clean the resident properly, and despite seeking help, did not follow proper hand hygiene protocols. The facility's personal care policy was not adhered to, compromising the resident's dignity and health.
A resident with severe cognitive impairment did not receive thorough incontinence care, as CNA D failed to clean the peri-area completely after a bowel movement. The CNA also neglected proper hand hygiene and glove use, increasing the risk of infection. Interviews confirmed non-compliance with facility protocols for perineal care.
A resident on a mechanical soft diet was served pot roast that was not ground as required, leading to an inability to consume the meal. Despite the resident's alertness and communication of his needs, the Dietary Manager and nursing staff were unaware of the specific dietary requirements, resulting in a failure to adhere to the facility's policy on mechanical soft diets.
A facility failed to include a smoking care plan for a resident with dementia, malnutrition, asthma, and COPD, who required supervision when smoking. Despite the resident's need for assistance with ADLs, the care plan lacked measures for smoking, confirmed by interviews with the resident and administrator.
A facility failed to label a Humalog insulin pen with an open date, risking the administration of ineffective medication. During an observation, an insulin pen was found without an open date, contrary to the facility's policy and professional standards. Interviews with the DON and ADON confirmed that insulin should be dated upon opening to ensure effectiveness, as it expires 28 days after being opened.
The facility failed to maintain a clean and safe environment, particularly on Hall 300, where equipment and resident rooms were found to be dirty and in disrepair. Observations revealed that the sit-to-stand lift and several residents' wheelchairs were covered in dust and debris, and Resident #2's room had multiple cleanliness issues, including a large unrepaired hole in the wall. Interviews with staff and residents highlighted a lack of a consistent cleaning schedule and unclear responsibilities, contributing to the deficiency.
A facility failed to secure residents' medication blister packs, leaving them unattended on a medication cart, which could lead to a breach of privacy. An LPN left the cart to assist a resident, exposing sensitive information. Despite recent HIPAA training, staff did not consistently follow procedures to secure such information.
A facility failed to maintain proper infection control when a piston syringe used for catheter flushing was left unwrapped on a resident's dresser. The resident, who had chronic urinary infections and required catheter care, was at risk due to this oversight. Staff interviews revealed a lack of accountability and adherence to infection control protocols, as the syringe should have been disposed of immediately after use.
A resident with cognitive impairment and high elopement risk left a facility unsupervised due to a door lacking an audible alarm. Despite being ambulatory with a wheelchair, the resident exited without triggering alarms, leading to a police search. Staff interviews indicated the resident often sat by exits but had not previously attempted to leave.
The facility failed to provide timely dental care for four residents, leading to prolonged dental issues and pain. Despite reporting their issues to the social worker, residents experienced significant delays in receiving dental services due to infrequent visits from a mobile dental service.
The facility failed to provide adequate supervision and safety measures for residents who smoke, specifically for two residents with intact cognition who were observed smoking without supervision. Despite being a non-smoking facility, 19 residents were known to smoke, and there was no smoking policy or designated staff to supervise smoking activities. Residents were not consistently signing out when leaving to smoke, and there was no documentation of education about smoking risks, leading to a deficiency in ensuring a safe environment.
The facility failed to implement a smoking policy, leading to unsupervised smoking by residents despite being a non-smoking facility. Two residents were observed smoking without staff supervision, keeping smoking materials in their rooms, and not adhering to any set schedule. Interviews revealed the facility had no formal smoking policy, placing residents at risk for injury and creating an unsafe environment.
A facility failed to ensure proper care for a resident with a feeding tube, as an LVN did not check for residual volume before administering medication. This oversight could lead to complications such as aspiration or vomiting. The resident, with severe cognitive impairment and requiring extensive assistance, was at risk due to this failure.
A LTC facility reported an 11% medication error rate involving two residents. An LVN administered Levemir instead of Lantus to one resident and incorrect doses of Vitamin B-12 and Folic acid to another. The facility's policy on medication administration was not followed, leading to these errors.
A facility failed to maintain an effective infection control program, as a CNA did not perform proper hand hygiene during incontinent care, and linens and trash were improperly managed in a resident's room, leading to a foul smell. The CNA admitted to not using available handwashing options, and the DON confirmed the expectations for hand hygiene and proper disposal of soiled items.
Failure to Prevent Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident at risk for elopement. The resident, a male with severe cognitive impairment, non-Alzheimer's dementia, anxiety, hypertensive heart disease, osteoarthritis, psychotic disorder, and intervertebral disc degeneration, was identified as high risk for elopement and placed in a secured unit. Despite this, the resident was able to exit the facility unsupervised by forcing open a window in a room near the TV area, which was found to have a compromised locking mechanism and no alarm at the time of the incident. On the night of the incident, staff last observed the resident in the TV room. During routine activities and medication administration, the resident was not directly supervised and was able to leave the secured unit undetected. Staff initiated a search and discovered a broken window with evidence of forced exit, including a sheared bolt and disturbed bushes outside. The resident was later found by emergency services in a nearby area, having sustained superficial abrasions and a compression fracture of the lumbar spine. Interviews with staff revealed that the window in question did not have an alarm prior to the incident and that the resident had not previously exhibited elopement behavior, though he was known to wander and was physically strong. The facility's elopement prevention policy required regular checks of exit devices, but the absence of an alarm and the compromised window allowed the resident to elope. Staff were occupied with other residents during the time of the incident, and the lack of direct supervision contributed to the resident's ability to leave the facility undetected.
Failure to Notify Physician and Family of Resident Incident and Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative and physician following a significant change in the resident's physical status. Specifically, a nurse entered the resident's room and accidentally hit the resident with the door. The nurse did not complete an incident report, document assessments, or initiate required ongoing monitoring for delayed injury. Additionally, the nurse did not notify the resident's responsible representative or physician about the incident or about the resident's broken dentures, which were discovered during the resident's stay. The resident involved was an elderly female with Alzheimer's disease, admitted for a short respite stay and was on anticoagulant medication, increasing her risk for bruising and injury. The resident was ambulatory, had wandering behaviors, and required a secured unit. During her stay, she was noted to have removed her upper dentures frequently, and staff later discovered the dentures were broken. The nurse reported the broken dentures to the Assistant Director of Nursing (ADON) but did not notify the family or physician at the time. When the resident's family arrived to pick her up, they observed bruises on her arms and forehead and noticed the broken dentures. They reported not being informed about the incident with the door, the lab work, or the broken dentures. Interviews with facility staff confirmed that the nurse did not document or report the incident or the broken dentures as required by facility policy, which mandates immediate notification and documentation of such events.
Failure to Maintain Safe and Hazard-Free Resident Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident who required substantial assistance with activities of daily living and was at risk for falls. Observations revealed that the resident's room contained a large extension cord running across the floor from the television to an outlet, despite there being an available outlet on the same wall as the television. Additionally, another extension cord was connected to two fans, and the bed adjuster on top of the resident's bed had exposed wires. During interviews, the Maintenance Supervisor acknowledged the presence of the extension cords and stated that they posed a tripping hazard and should not have been used. He also noted that the exposed wires on the bed adjuster, while a low shock risk, should not be exposed. The Administrator was not aware of these hazards until informed and agreed that such conditions could lead to fire or falls. The facility's policy requires maintaining an environment that promotes quality of life and protects resident rights, but these conditions were not met in this instance.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident who was dependent for activities of daily living (ADLs) received scheduled showers as required by her care plan. The resident, who had a history of cerebral infarction with reduced mobility and required total assistance for ADLs, did not receive any of her scheduled showers for over five weeks, except for one shower after she complained to leadership. Shower and bath records for November and December showed only sporadic documentation of bed baths and one shower, with some dates lacking any indication of care provided. The resident reported that staff told her they did not have time to provide showers and that the shower bed was broken. Interviews with staff revealed inconsistent practices regarding the assignment of CNAs to resident halls and a lack of oversight in ensuring that scheduled showers were provided and properly documented. Nurses and the ADON acknowledged that the resident should have received showers or bed baths at least three times a week, and that failure to do so could result in negative outcomes. However, there was no evidence that the required showers were consistently provided or that refusals were properly documented, as required by facility policy and the resident's care plan.
Failure to Coordinate Hospice Services and Obtain Required Documentation
Penalty
Summary
The facility failed to obtain essential hospice documentation and coordinate care for a resident admitted for a respite stay while receiving hospice services. Specifically, the facility did not secure the hospice election form, hospice plan of care, or physician certification and recertification of terminal illness from the hospice agency. Additionally, there was no designated member of the facility's interdisciplinary team responsible for coordinating with hospice representatives to ensure the resident's care was managed appropriately. During the resident's respite stay, the facility did not coordinate with Hospice Agency J to ensure the continuation of hospice aide services, resulting in the resident not receiving scheduled hospice aide visits for several days. Interviews revealed that staff were unclear about the hospice services to be provided, and there was confusion regarding the hospice aide's schedule and responsibilities. The facility staff relied on their usual procedures with other hospice agencies, but this was a new agency, and necessary communication and documentation were lacking. The resident involved was an elderly female with Alzheimer's disease, admitted for a short-term respite stay. She was ambulatory, required minimal assistance, and had a history of short-term memory impairment and wandering behaviors. Despite being scheduled for showers and some assistance, the lack of coordination between the facility and hospice agency led to missed hospice aide services, as neither party ensured the aide visits occurred or communicated effectively about the resident's care plan.
Failure to Provide Privacy Curtain Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a female resident with major depressive disorder, anxiety, and moderate cognitive impairment was found to be without a privacy curtain in her shared room for approximately four weeks. The resident reported having to use the bathroom to change clothes due to concerns about privacy, as anyone could enter the room while she was changing. Observation confirmed the absence of a privacy curtain, and the resident expressed discomfort with the situation. Staff interviews revealed that the LVN assigned to the hall was aware of the missing curtain but did not know why it was absent. The ADON and Administrator were not previously aware of the issue and speculated that laundry may have removed the curtain for cleaning. The resident's roommate had a privacy curtain, but this did not provide privacy for the affected resident. Facility policy requires that residents be treated with dignity and respect, including the provision of a private environment.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. The resident, an elderly male with severe cognitive impairment and multiple medical diagnoses including dehydration, coronary artery disease, and benign prostatic hyperplasia, required maximum assistance with personal hygiene according to his care plan. Despite this, observations on the specified date revealed that the resident's fingernails were overgrown, discolored, and had brown matter underneath. The resident expressed a desire to have his fingernails trimmed and cleaned. Record review showed that his last bed bath was two days prior and his last shower was several days before the observation. Interviews with staff, including a CNA, LVN, and the ADON, confirmed that both CNAs and nurses were responsible for nail care, with nurses specifically handling nail care for diabetic residents. Staff acknowledged that nail care should be performed on shower days and as needed, and that dirty, long nails could pose an infection risk. The facility's policy required regular nail management to promote cleanliness and prevent infection, typically during bathing. However, the resident's nail care needs were not met as required by his care plan and facility policy.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program as required, specifically in the disinfection of reusable resident care equipment. During a medication pass, a Certified Medication Aide (CMA) used a blood pressure cuff on two different residents without disinfecting it between uses. Observations showed that the CMA took the blood pressure cuff from the medication cart, used it on one resident, returned it to the cart without sanitizing, and then used the same cuff on another resident without cleaning it in between. The CMA stated in an interview that she cleaned the cuff at the start of her shift and twice during her shift, but also claimed to sanitize it between residents, which was not observed. The facility's policy requires non-invasive resident care equipment to be cleaned daily or as needed between use by nursing assistants, and immediately if visibly soiled. Interviews with the Regional Nurse and the Assistant Director of Nursing (ADON) confirmed that staff are trained and expected to disinfect reusable equipment between residents, in accordance with the facility's infection control policy. Both acknowledged that failure to do so poses a risk of cross-contamination. Record review of the facility's infection control policy further supported the requirement for cleaning equipment between resident use. The deficiency was identified through direct observation, staff interviews, and review of facility policy.
Failure to Ensure Safe and Documented Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had a complex medical history including dementia, schizoaffective disorder, morbid obesity, and multiple physical health conditions, was discharged following an incident involving bodily harm to another resident. Despite the resident's significant care needs and cognitive impairments, there was no evidence that the facility ensured the discharge destination could meet her needs or that the resident and her representative were adequately prepared for the transition. Record reviews revealed that the resident was discharged home with medications and some instructions, but without home health services or documented referrals for psychiatric observation. The discharge summary indicated that the resident's representative was unable to care for her due to work obligations and physical limitations, and the resident ultimately did not go to the representative's home but to another family member's residence. There was no documentation that the representative declined alternate placement, received ombudsman contact information, or was provided with a written or verbal notice of intent to leave the facility. Staff interviews confirmed that the discharge was not safe, as the representative could not properly care for the resident, who required 24-hour licensed nursing care. The facility's own discharge policy required assessment of the discharge destination's ability to meet the resident's needs, involvement of the resident or representative in planning, and documentation of referrals and responses. These steps were not followed or documented in this case. The lack of preparation and failure to ensure a safe discharge destination resulted in the resident being placed in an inappropriate setting, leading to further intervention by authorities and eventual transfer to a psychiatric hospital.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart was observed unlocked, unattended, and not under the direct observation of authorized staff. The lock was in the out position, allowing anyone to open the drawers and access various multi-dose bottles of over-the-counter medications, as well as residents' routine and PRN medications and medication blister packs. During this time, a resident was seen ambulating back and forth in the hallway near the unattended cart. The medication technician responsible for the cart was not present at the cart and was observed returning from approximately twenty-five feet away. During an interview, the medication technician acknowledged that she should not have left the medication cart unlocked and unattended, stating that she was aware of the policy and had received training during new hire orientation. The facility's policy requires that medication carts remain locked when not in use or not attended by authorized personnel, and only licensed nurses, pharmacy staff, and those lawfully authorized are permitted access to the carts.
Failure to Maintain Safe and Comfortable Resident Environment Due to Missing Vent Cover and Damaged Furniture
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in one of five rooms observed. In the identified room, the metal vent cover was missing from the air conditioning opening in the ceiling, and a large amount of black substance was observed attached to the metal tubing inside the opening. Warm air was blowing out of the opening, and the room was warm with no air circulating. Additionally, the built-in dresser in the room was missing four drawers and two doors, leaving resident clothing exposed and metal brackets accessible, which could be hazardous. The resident occupying the room had a history of acute and chronic respiratory failure with hypercapnia, COPD with acute exacerbation, and essential hypertension. The resident required continuous oxygen and reported difficulty sleeping and breathing at night due to the room being too hot. During observation, the resident was using oxygen while in a wheelchair and stated the need for oxygen 24 hours a day. The care plan for the resident included interventions to monitor respiratory status and ensure adequate oxygenation. Interviews with facility staff revealed that the maintenance assistant, who was new to long-term care, was checking room temperatures due to high outdoor temperatures. The assistant noted that the vent cover had fallen off and acknowledged that the lack of a cover allowed warm air to enter the room, making it warmer. The administrator was unaware of the missing vent cover but was aware of the dresser's condition, stating it could not be repaired before the resident moved in. Facility policy on air conditioning failures was reviewed, but the observed deficiencies in the room environment were not addressed prior to the survey.
Failure to Implement Fall Prevention Intervention as Outlined in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident identified as high risk for falls. The resident, a male with diagnoses including unspecified Parkinsonism, involuntary abnormal movements, cognitive communication problems, and prostate cancer, was dependent on staff for activities of daily living and had a history of falls. His care plan, revised in April, specified the use of a floor mat as a fall prevention intervention. On the date of the incident, the resident was observed in bed without the required floor mat in place, despite being awake and attempting to climb out of bed. Staff interviews revealed that the floor mat was not present because it may have been removed for cleaning or to prevent tripping hazards, and the assigned CNA was unaware of the resident's need for a floor mat due to lack of familiarity with his care plan. Further interviews with nursing staff and facility leadership confirmed that the floor mat was a required intervention for fall prevention and should have been in place whenever the resident was in bed. The facility's policy on fall prevention emphasized the importance of implementing individualized interventions and educating staff about safety measures. The failure to ensure the floor mat was in place as specified in the care plan resulted in noncompliance with the requirement to provide comprehensive care planning and implementation for the resident's needs.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a stroke, who required staff assistance for bathing, was not provided showers as scheduled. Record reviews showed missing documentation for several scheduled shower days, and there was no evidence in nursing notes that the resident refused showers. The resident reported not receiving a shower for a week and expressed discomfort and dissatisfaction with the lack of bathing. Staff interviews confirmed the importance of documenting showers and monitoring that residents receive them, but documentation was missing for the relevant dates. The facility's policy outlined the goals and procedures for bathing but did not specify requirements for documenting showers or refusals. The ADON and DON acknowledged the need for proper documentation and monitoring, and the administrator stated that care should be provided as scheduled and documented. The lack of documentation and missed showers for the resident led to the deficiency, as the necessary services to maintain personal hygiene were not consistently provided or recorded.
Failure to Ensure Daily Emergency Cart Checks and CPR Readiness
Penalty
Summary
The facility failed to ensure that personnel provided basic life support, including CPR, to a resident requiring emergency care prior to the arrival of emergency medical personnel, as required by physician orders and the resident's advance directives. Specifically, the facility did not complete daily inventory checks on Emergency Response Cart 1 for a period of time, and the inventory log was found to be incomplete on one occasion, with several critical items such as a backboard, blood pressure cuff, stethoscope, and other supplies not checked off. Interviews with nursing staff and administration confirmed that the night shift was responsible for these checks, but the process was not consistently followed, and the charge nurses were expected to monitor compliance. Staff acknowledged the importance of these checks to ensure all necessary items were available in an emergency. Further review revealed that the facility did not have a policy for Cardiopulmonary Resuscitation (CPR), and the Central Supply Reference Guide required all emergency carts to be checked for expired items. The lack of daily checks and incomplete documentation could result in missing or expired emergency supplies, potentially delaying emergency response care. The deficiency was identified through observation, interview, and record review, and involved Emergency Response Cart 1 on the C hallway.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and report abuse, neglect, and exploitation of residents, as evidenced by the case of a resident who sustained injuries of unknown origin. The resident, who had a history of Huntington's disease, dementia, and repeated falls, was found with a large bruise on her right and left eyes and a laceration on her right eyebrow. Despite these injuries, the facility staff did not report them to the abuse and neglect coordinator, which is a requirement under the facility's policy. The resident's medical records indicated that she had severe cognitive impairment and required substantial assistance for daily activities. On a particular day, the resident was minimally responsive and was sent to the ER for further treatment. A skin assessment revealed multiple bruises and abrasions, but these were not reported or investigated as required. Interviews with staff members revealed that several of them noticed the injuries but failed to report them to the appropriate authorities, citing various reasons such as assuming the injuries were old or not suspicious. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the failure to report and investigate the injuries. They noted that the injuries could have been related to the resident's condition, but emphasized that any injury of unknown origin should have been reported and investigated. The facility's policy clearly states that all potential abuse or neglect incidents must be reported and investigated, but this protocol was not followed in this case, leading to a deficiency in the facility's care standards.
Failure to Document Blood Pressure Monitoring for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not adhering to physician orders regarding the administration of Propranolol, a beta blocker medication. The medication was prescribed to be administered only if the resident's blood pressure was above 110/60. However, there was no documented evidence in the clinical record to indicate that the resident's blood pressure was taken to validate the need for the medication. This oversight occurred for a period from December 1, 2024, through January 18, 2025, with the exception of a few instances in December. The resident involved was an elderly female with a history of hypertension, Huntington's disease, dementia with mood disturbance, and repeated falls. Her care plan did not include a focus area for hypertension or related interventions, despite her being at risk for falls due to her medical conditions. The resident's blood pressure readings were not consistently documented, with only a few readings recorded in December and none in January up to the 18th. Interviews with facility staff revealed that there was a lack of proper documentation and communication regarding the blood pressure monitoring required before administering the medication. The Assistant Director of Nursing (ADON) and a Medication Aide (MA) acknowledged the importance of taking and documenting blood pressure readings but noted that the Medication Administration Record (MAR) did not have a designated area for recording these readings. The MA stated that she took the resident's blood pressure and recorded it on paper during her shift but destroyed the notes at the end of the day, leading to a lack of permanent documentation in the resident's records.
Failure to Complete PASARR Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness received the appropriate Pre-Admission Screening and Resident Review (PASARR) evaluations. Specifically, seven out of ten residents reviewed did not have the necessary PASARR Level 2 evaluations completed. This deficiency was identified through interviews and record reviews, which revealed that several residents with serious mental illnesses were not properly assessed, potentially placing them at risk of not receiving the specialized services they require. Resident #104, for instance, had a PASARR Level 1 screening that incorrectly indicated no serious mental illness, despite having diagnoses such as schizophrenia and psychotic disorder. The Director of Nursing (DON) and MDS Nurse were unaware of the reason for this discrepancy, and the resident's care plan included services for schizophrenia, highlighting the need for a Level 2 evaluation. Similarly, Resident #82 was identified as having a mental illness in the PASARR Level 1 screening, but there was no record of a referral to the Local Mental Health Authority (LMHA) for a Level 2 screening, as confirmed by the facility's social worker and MDS Nurse. Other residents, such as Resident #5 and Resident #14, did not have any PASARR evaluations completed, despite having diagnoses that warranted such assessments. Interviews with the MDS Nurse and DON revealed a lack of awareness and oversight regarding the completion of these evaluations. The facility's policy on PASARR maintenance was not adhered to, resulting in residents being at risk of not receiving the necessary care and management for their mental health conditions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not perform proper hand hygiene while providing incontinence care to a resident with severe cognitive impairment. The CNA failed to clean the resident's peri-area thoroughly, did not change gloves or perform hand hygiene between tasks, and handled soiled materials without gloves, increasing the risk of infection transmission. Additionally, the facility did not implement enhanced barrier precautions for two residents who were at increased risk of infection due to their medical conditions. One resident, who had multiple wounds and a peripherally inserted central catheter (PICC), did not have the necessary precautions in place, such as gown and glove use during high-contact care activities. The staff did not wear gowns while administering medications and performing wound care, contrary to the guidelines for residents with wounds or indwelling medical devices. Another resident with pressure ulcers and a PermaCath for dialysis also lacked enhanced barrier precautions. Staff did not wear gowns during care activities, including repositioning and dressing changes, despite the resident's risk factors. The facility's infection preventionist acknowledged the oversight and the potential for infection transmission due to the lack of appropriate precautions.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed that food items in the dry storage, refrigerator, and freezer areas were not labeled and dated according to guidelines. Additionally, open items were not sealed properly in plastic bags, and expired items were not removed from these storage areas. These practices could potentially affect residents who receive meals and snacks from the main kitchen, placing them at risk for cross-contamination and airborne illnesses. During the initial tour of the kitchen, several expired items were found, including thickened unflavored water, thickened orange juice, thickened cranberry cocktail, and thickened sweet tea. Other items such as spaghetti noodles, baking soda, squeezable honey, and creamy peanut butter were found unsealed. In the freezer, a container of thickened cranberry cocktail was also expired. In the refrigerator, a container of mixed fruit and a tray of ketchup cups were not properly sealed. These findings indicate a lack of adherence to food safety protocols, which require items to be sealed, labeled, and dated to prevent spoilage and contamination. Interviews with the Dietary Manager, a staff member, and the Dietary Aide revealed that all staff were responsible for ensuring that items in the kitchen were not expired and were properly sealed. Despite receiving in-service training on food preparation and storage, staff were unaware of the expired and unsealed items. The facility's policy on food storage and supplies emphasizes the importance of maintaining storage areas in an orderly manner to preserve food condition, but the observed practices did not align with these guidelines. The failure to follow these procedures could lead to the risk of airborne illnesses if contaminated food is ingested.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident #98, as evidenced by a broken windowsill in her room that was not repaired in a timely manner. The windowsill was broken in the middle, leaving exposed adhesive and particle board, with loose wood debris present. This condition was observed by staff, including an LVN who noted that the windowsill had been in this state since he began working at the facility in October 2024. Despite the presence of a maintenance log system, there were no entries related to the windowsill, indicating a lack of communication and follow-up on the issue. Resident #98, a female with severe cognitive impairment and multiple medical conditions, including kidney failure, pneumonia, and anoxic brain damage, was affected by this deficiency. She was non-verbal, fed by a feeding tube, and required oxygen through a tracheostomy. The broken windowsill was located in her room, where she spent significant time due to her medical needs. The Social Worker and Maintenance Staff were made aware of the issue on December 8, 2024, but it was not addressed until the following day when the resident and her roommate were moved to another room for repairs. Interviews with facility staff revealed a lack of awareness and urgency in addressing the broken windowsill. The Maintenance Supervisor and Social Worker both acknowledged the issue but were unsure of when it was first reported or the potential safety risks it posed. The facility's policy on resident rights emphasizes the importance of maintaining a safe and comfortable environment, yet this incident highlights a failure to adhere to these standards, potentially impacting the quality of life for Resident #98.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, muscle weakness, and lack of coordination, was observed in bed with a soiled blanket and brief. Despite being dependent on staff for personal hygiene, the resident did not receive timely assistance. A Certified Nursing Assistant (CNA) initially attempted to clean the resident but did not thoroughly remove all bowel movement from the peri-area, leaving the resident at risk for infection. The CNA left the room to seek additional help, returning with another CNA to complete the cleaning process. However, the CNA did not perform hand hygiene after changing gloves and tore a glove while applying fresh linen, further compromising the care process. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA had vision problems, which may have contributed to the inadequate cleaning. The facility's policy on personal care emphasizes maintaining resident dignity and preventing infections, but these standards were not met in this instance.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident with severe cognitive impairment and dependency on staff for personal hygiene. During an observation, CNA D did not thoroughly clean the resident's peri-area after a bowel movement, leaving the area soiled. Despite using toilet paper and wipes, CNA D did not remove all the bowel movement from the resident's peri-area before placing a new brief on the resident. This incomplete cleaning was noted by the surveyor, prompting CNA D to seek assistance from another CNA. CNA D also failed to adhere to proper hand hygiene protocols during the incontinence care process. He changed gloves multiple times without performing hand hygiene, which is crucial to prevent the spread of infection. Additionally, CNA D wore torn gloves and handled soiled linen and trash without gloves, further increasing the risk of contamination and infection. Interviews with the facility's infection preventionist and DON confirmed that the staff did not follow the required procedures for glove use and hand hygiene. The facility's policy outlined specific steps for providing perineal care, including washing and rinsing the genital and rectal areas from front to back, which were not fully adhered to by CNA D. The failure to thoroughly clean the resident and maintain proper hygiene practices placed the resident at risk for infection.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident on a mechanical soft diet. The resident, who had difficulty swallowing and required a mechanically altered diet, was served pot roast that was not ground as required by his dietary needs. Despite the resident's alertness and ability to communicate his needs, he was unable to eat the meat due to its inappropriate texture, which was observed to be in large chunks rather than finely chopped or ground. Interviews with the Dietary Manager and nursing staff revealed a lack of awareness and communication regarding the resident's specific dietary requirements. The Dietary Manager acknowledged the importance of serving the correct texture to prevent choking or aspiration but was unaware of the resident's inability to consume the pot roast. The ADON and DON also confirmed the oversight, with the DON admitting unfamiliarity with the facility's policy on mechanical soft diets. The facility's policy specified that the mechanical soft diet should include minced and moist meat with specific particle size requirements, which were not met in this instance.
Failure to Address Smoking in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's smoking habits. The resident, a male with Non-Alzheimer's Dementia, Malnutrition, Asthma, and Chronic Obstructive Pulmonary Disease, required moderate assistance with activities of daily living and supervision when smoking. Despite these needs, the resident's comprehensive care plan did not include any measures or objectives related to smoking, as revealed in a review of the care plan dated 10/15/24. Interviews conducted with the resident and the facility's administrator confirmed the absence of a smoking care plan. The resident did not provide details about his smoking habit, while the administrator acknowledged the oversight and emphasized the importance of including smoking in the care plan to ensure staff and other providers are aware of the resident's needs. The facility's policy mandates the development of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, specifically concerning the labeling of an insulin pen. During an observation of the medication cart, it was found that a Humalog insulin pen was open without an open date. This oversight was confirmed by LVN A, who acknowledged that insulin expires 28 days after opening and that without proper labeling, the medication could lose potency and become ineffective. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that there was an expectation for unit managers to check for expired medications weekly and for pharmacists to conduct monthly checks. Both the DON and ADON C stated that insulin should be dated upon opening to prevent the administration of expired medication, which could be ineffective. The facility's policy on medication storage, revised in 2012, also reflected the requirement for insulins to be labeled with expiration dates after opening.
Deficiency in Maintaining a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for residents, particularly on Hall 300. Observations revealed that the sit-to-stand mechanical lift was covered in layers of dust and debris, indicating a lack of regular cleaning by the housekeeping and nursing departments. Additionally, Resident #2's room was found to have multiple cleanliness issues, including stains on the G-tube machine, bed frame, and light fixture, as well as a large unrepaired hole in the wall. This resident, who is nonverbal and severely cognitively impaired, relies entirely on staff for all activities of daily living. Several residents' wheelchairs, including those of Residents #5, #6, #7, and #8, were observed to be dirty, with layers of dust and debris on various parts of the wheelchairs. Interviews with residents and staff revealed that there was no consistent schedule or system in place for cleaning wheelchairs, leading to neglect in their maintenance. Resident #5, who has no cognitive impairment, expressed dissatisfaction with the cleanliness of his wheelchair, which he had previously reported to the administration without resolution. Similarly, Resident #6, who has mild cognitive impairment, reported that his family member had to clean his wheelchair due to the facility's inaction. Interviews with various staff members, including CNAs, LVNs, and the Maintenance Director, highlighted a lack of clarity and responsibility regarding the cleaning of equipment and maintenance of the facility. The Maintenance Director was unaware of the hole in Resident #2's room and acknowledged the absence of a designated person or system for ensuring wheelchair cleanliness. The Director of Rehabilitation and Housekeeping Supervisor also confirmed the absence of a structured cleaning schedule, contributing to the overall deficiency in maintaining a safe and clean environment for residents.
Failure to Secure Residents' Medication Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as observed during a survey. Specifically, the facility did not ensure that medication blister packs for four residents were secured, leading to a potential breach of privacy. The blister packs, which contained sensitive information such as the residents' names, medication details, and diagnoses, were left unattended on top of a medication cart outside a resident's room with the door closed. The incident occurred when LVN A left the medication cart unattended to assist a resident who appeared to be falling out of bed. During this time, the blister packs were exposed, allowing anyone passing by to potentially view the private information. LVN A acknowledged the mistake, stating that the blister packs should have been secured in the medication cart until they could be properly disposed of in a shredder box. Interviews with other staff members, including LVN B, ADON C, the DON, and the Administrator, revealed a lack of consistent adherence to HIPAA guidelines regarding the handling of empty blister packs. The facility's policy required that such items be kept inside the medication cart and locked if unattended. Despite recent HIPAA training, the staff did not consistently follow these procedures, resulting in the observed deficiency.
Infection Control Deficiency Due to Improper Syringe Disposal
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a piston syringe used for flushing a urinary catheter. During an observation, a piston syringe was found unwrapped and left on a dresser in a resident's room, surrounded by personal belongings, including a toothbrush and snacks. This oversight was noted during a survey, and the staff present could not identify who left the syringe there, indicating a lapse in adherence to infection control protocols. The resident involved was an elderly female with a history of respiratory failure, stage 4 ulcers, and total dependence on assistance for activities of daily living. She was also oxygen-dependent and had a suprapubic catheter due to chronic urinary infections. The resident's medical records indicated that her catheter was to be flushed with normal saline as needed, but there was no documentation of this procedure being performed in the treatment administration records. Interviews with various staff members, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurses (LVNs), and the Director of Nursing (DON), revealed a lack of clarity and accountability regarding the proper disposal of the syringe. The staff acknowledged that leaving the syringe in the resident's room posed a risk of infection, especially given the resident's existing chronic infections. The facility's infection control policy required the immediate disposal of syringes after use, but this protocol was not followed, leading to the deficiency noted by the surveyors.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically for a resident who left the facility unsupervised. The resident, who had a history of heart failure, schizophrenia, cognitive impairment, and end-stage renal disease, was assessed as having a high risk for elopement. Despite this, the resident was able to leave the facility without supervision, as there was a door near the secure unit that did not have an audible alarm. The resident was last seen sitting by one of the exits of the secured unit before 10:00 p.m. and was later found at a hospital emergency room the following day. The facility's records indicated that the resident was ambulatory using a wheelchair as a walker and had a history of sitting by exit doors without attempting to leave. However, on this occasion, the resident managed to exit the facility, leading to a search involving the police and the use of search dogs. Interviews with staff revealed that the resident often talked about checking on her family but had not previously attempted to leave the facility. The staff was unaware of any alarms being triggered, and the facility's alarm system was reportedly checked and found to be functioning properly. The incident highlighted a lapse in supervision and security measures, as the resident was able to leave the facility without setting off any alarms.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining routine and 24-hour emergency dental care for four residents from December 2023 through May 17, 2024. Resident #3, a woman with multiple serious health conditions including chronic osteomyelitis and type 2 diabetes, reported a dental issue to the social worker in December 2023 but was not scheduled to be seen by the dentist until May 25, 2024. Despite persistently asking for dental care, her issue remained unaddressed for several months. Resident #4, who has multiple sclerosis and other severe health issues, reported that she did not receive regular oral care and had not seen a dentist in a long time. Observations confirmed plaque buildup on her lower teeth. Although her care plan indicated she required total assistance with personal hygiene, her request for more frequent teeth brushing was not consistently met. Resident #7, a man with schizophrenia and other mental health conditions, reported ongoing dental pain that was not resolved despite multiple visits to the dentist. He informed the social worker about his dental issues, but his pain persisted. Similarly, Resident #8, a woman with ataxia and other health issues, reported a cavity and experienced a long wait for a dental appointment, only to be told the dentist was done for the day. She had been waiting for dental care for about five months. Interviews with staff revealed that dental issues were referred to the social worker, who scheduled appointments with a mobile dental service that visited the facility infrequently, leading to delays in care.
Lack of Supervision and Smoking Policy for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents who smoke, specifically for two residents reviewed for accidents, hazards, and supervision. Resident #81, a male with diagnoses including dementia, alcohol dependence, and tobacco use, was observed smoking without supervision at the back entrance of the facility. Despite being aware that the facility was non-smoking, Resident #81 kept cigarettes and a lighter in his possession and was not informed of any consequences for smoking. The care plan for Resident #81 did not address smoking, and there was no staff supervision when residents smoked outside. Similarly, Resident #11, a male with diagnoses including type 2 diabetes and muscle weakness, was found to have cigarettes and a lighter in his bedside nightstand. He smoked multiple times a day without a set schedule and without supervision. The facility's Director of Nursing (DON) and Administrator acknowledged that the facility was non-smoking, yet 19 residents, including Resident #11, were known to smoke. The facility did not have a smoking policy, and residents were not required to sign out when they went to smoke, leading to a lack of supervision and control over smoking activities. Interviews with staff, including the DON and an LVN, revealed that there was no designated staff to supervise smoking activities, and residents were not consistently signing out when leaving to smoke. The facility did not have a smoking policy despite having residents who smoked, and there was no documentation of education provided to residents about the risks of smoking. The lack of supervision and absence of a smoking policy contributed to the deficiency in ensuring a safe environment for residents who smoke.
Lack of Smoking Policy and Supervision in Non-Smoking Facility
Penalty
Summary
The facility failed to establish and implement a smoking policy in accordance with applicable Federal, State, and local laws and regulations, which affected the safety of residents who smoked. Specifically, the facility did not have a policy addressing the signing in and out of residents on a Release of Responsibility for Leave of Absence form for smoking purposes. This deficiency was observed in two residents, both of whom were able to smoke without supervision and without adhering to any set schedule or designated smoking area. Resident #81, a male with diagnoses including dementia, alcohol dependence, and tobacco use, was observed smoking outside the back entrance of the facility without staff supervision. Despite the facility being designated as non-smoking, Resident #81 kept cigarettes and a lighter in his room and was not informed of any consequences for smoking. Similarly, Resident #11, who had type 2 diabetes and required assistance with daily living activities, also smoked without a set schedule and kept smoking materials in his room. Both residents were aware of the facility's non-smoking status but continued to smoke without intervention from staff. Interviews with staff, including the DON and the Administrator, revealed that the facility did not have a formal smoking policy, despite having 19 residents who smoked. The facility relied on residents signing out when they went to smoke, but there was no designated staff to ensure compliance. The lack of supervision and formal policy placed residents at risk for injury and created an unsafe smoking environment. The facility's approach was to inform residents of the non-smoking policy upon admission and offer nicotine patches, but there was no documentation of education or follow-up to ensure residents adhered to the policy.
Failure to Check Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications. Specifically, a Licensed Vocational Nurse (LVN) did not check for residual volume before administering medication through the resident's feeding tube. This oversight could lead to potential complications such as aspiration or vomiting. The resident in question, a female with severe cognitive impairment, required extensive assistance with activities of daily living and had a feeding tube due to her medical conditions, including gastrostomy status, dysphasia, and cerebral palsy. During an observation, the LVN was seen administering several medications through the feeding tube without checking for residual volume, which is a necessary step to ensure the resident is not being overfed. The LVN admitted to forgetting this step and acknowledged the importance of checking residuals to prevent overfeeding and its associated risks. The Director of Nursing (DON) confirmed that the LVN was supposed to check the residuals before medication administration to avoid potential complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11% error rate based on three out of 27 opportunities. This involved two residents who were affected by medication administration errors. One resident, a 71-year-old female with diagnoses including reduced mobility and morbid obesity, was administered Levemir instead of the prescribed Lantus insulin. The error was observed during a medication pass, where the LVN administered Levemir 18 units instead of the prescribed Lantus 18 units. The resident's medication administration record indicated the correct medication was Insulin Glargine, but the LVN failed to administer it as ordered. Another resident, with severe cognitive impairment and requiring extensive assistance, was administered incorrect doses of Vitamin B-12 and Folic acid. The LVN administered Vitamin B-12 1000 mcg instead of the prescribed 500 mcg and Folic acid 800 mcg instead of 1 mg. These errors were observed during a medication pass, where the LVN did not adhere to the prescribed dosages. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, which were not followed in these instances.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two main deficiencies observed during the survey. Firstly, a Certified Nursing Assistant (CNA) failed to perform proper hand hygiene while providing incontinent care to a resident. The CNA did not complete hand hygiene after changing gloves during the care process, citing the absence of hand sanitizer in the room and the restriction against carrying it in pockets. The CNA acknowledged the oversight and admitted that handwashing with soap and water was an option that was not utilized. Secondly, the facility did not ensure that linens and trash were properly managed in a resident's room and bathroom. Linens and a used brief were found on the floor, contributing to a foul smell in the room. The CNA responsible for the care admitted to forgetting to bring trash bags, which led to the improper disposal of soiled items. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene with every glove change and that linens and soiled briefs should not be left in rooms to prevent odors and potential infection risks.
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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