Focused Care At Linden
Inspection history, citations, penalties and survey trends for this long-term care facility in Linden, Texas.
- Location
- 1201 W Houston St, Linden, Texas 75563
- CMS Provider Number
- 675293
- Inspections on file
- 28
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Focused Care At Linden during CMS and state inspections, most recent first.
A resident with multiple comorbidities experienced right knee pain and swelling, prompting a STAT x-ray order. Although the imaging was performed and results indicating fractures were available in the facility's portal, staff did not review or communicate the findings to the physician for four days, resulting in a delay in treatment. Staff interviews revealed unclear follow-up procedures and lack of timely handoff regarding pending diagnostic results.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
A resident with significant mobility and cognitive impairments was injured when an LVN provided incontinent care without ensuring the bed was locked, resulting in the bed rolling into a wall. The incident caused the resident to sustain fractures to the left foot and wrist, as well as bruising and abrasions. Facility staff confirmed the bed's brakes were mostly functional, and policies did not specifically require beds to be locked during care.
A resident with moderate cognitive impairment and a history of behavioral issues alleged that a staff member threw a blanket at her face and used inappropriate language. The allegation was reported to several staff members, including an LVN and a Social Worker, but was not reported to the Abuse Coordinator within the required timeframe, resulting in a delay of approximately three hours before the appropriate authority was notified, in violation of facility policy.
A resident with multiple medical conditions, including stage 3 pressure ulcers, was admitted to a facility without immediate wound care orders. The facility failed to initiate wound care treatment promptly, leading to a delay in care. Staff interviews revealed a lack of communication and understanding of procedures for obtaining and implementing wound care orders, and the resident was not provided with necessary pressure-relieving devices.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment and care. One resident did not receive timely wound care or a specialty mattress, and their weekly skin assessments were not performed. Another resident lacked documented wound care and weekly skin assessments, raising concerns about the care provided. A third resident also experienced similar issues, with the facility's staff failing to consistently follow through with wound care orders and documentation.
The facility failed to conduct annual competency evaluations for five RCPs, as required by policy. Personnel files lacked documentation of these evaluations, and interviews with the DON and Administrator revealed uncertainty about their completion. This oversight could affect the quality of care provided to residents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with a history of falls and weight loss did not have these issues included in her care plan. Another resident's antiplatelet medication was not reflected in her care plan. Additionally, a resident requiring Enhanced Barrier Precautions did not have the necessary signage posted, indicating a lack of coordination in care planning.
The facility failed to provide adequate respiratory care for several residents, as evidenced by missing or dirty oxygen concentrator filters and improper storage of equipment. Residents with conditions such as cerebrovascular disease, heart failure, and COPD were affected. Staff interviews revealed confusion over responsibilities for maintaining oxygen equipment, leading to deficiencies in care.
Two residents in a LTC facility did not receive multiple essential medications due to failures in the pharmaceutical services. Medications for conditions like epilepsy, depression, and hypertension were unavailable on several occasions, as documented in the MAR. Staff interviews revealed issues with the medication ordering process, including delays in pharmacy delivery and communication problems. The facility's policy for timely medication ordering was not effectively followed, leading to these deficiencies.
A resident with severe mobility issues and cognitive impairment was repeatedly found with her call light out of reach, placed on her paralyzed side. Despite staff acknowledging the importance of keeping call lights accessible, the facility failed to ensure this accommodation, leading to potential delays in assistance and emotional distress for the resident.
A resident with a new diagnosis of Bipolar Disorder did not receive an updated PASRR, potentially affecting their access to necessary services. The facility's MDS Coordinator failed to complete the required documentation to reflect the resident's mental illness, as the previous MDS nurse did not update the necessary forms. This oversight was acknowledged by facility staff, who recognized the potential impact on the resident's care.
A resident with diagnoses of Major Depressive Disorder, Schizoaffective Disorder, and Bipolar Disorder was incorrectly marked as not having a mental illness on the PASRR Level 1 screening. The MDS Coordinator, responsible for completing PASRR evaluations, failed to ensure the assessment accurately reflected the resident's mental health status, as confirmed by the Director of Nurses. This oversight was contrary to the facility's PASRR policy, potentially impacting the resident's access to necessary services.
A resident admitted with multiple health issues did not receive a summary of their baseline care plan within 48 hours, as required. Staff interviews revealed confusion about responsibilities for completing and distributing the care plan. The facility's policy mandates completion and provision of the care plan summary within 48 hours, which was not followed.
A resident with multiple health issues did not receive necessary assistance with ADLs, including oral care and bed baths, since admission. Staff interviews revealed a lack of adherence to protocols, and the facility lacked a specific policy on ADL care, leading to oversight in providing essential services.
The facility failed to provide adequate supervision and safety for two residents. One resident, who was cognitively intact, had unauthorized rubbing alcohol in his room, posing a risk of accidental ingestion. Another resident, who was severely cognitively impaired, had exposed electrical wiring in his room, which was not reported or repaired as per facility policy. These lapses in supervision and safety measures could lead to potential harm.
The facility failed to provide proper catheter care and infection control for residents with urinary catheters, leading to potential risks of UTIs and other complications. A resident did not receive appropriate incontinent and catheter care, with improper hand hygiene and glove changes by staff. Two residents lacked securement devices for their catheters, increasing the risk of dislodgement and injury. Documentation of catheter care was also missing, indicating failures in monitoring and documentation processes.
A facility failed to maintain nutritional parameters for a resident with multiple health conditions, including Asperger's syndrome and epilepsy. The resident was not weighed weekly as required upon admission and readmission, and dietary recommendations to change health shakes were not followed. This led to a significant weight loss of 13.4% over 30 days. Staff interviews revealed a lack of clarity and coordination in responsibilities for weight monitoring and dietary interventions.
A facility failed to follow proper procedures before installing bed rails for a resident with multiple medical conditions, including Asperger's syndrome and epilepsy. The facility did not attempt alternatives, obtain informed consent, or conduct a bed rail assessment, posing a potential safety risk. Observations showed the resident had assist bars on both sides of her bed, but staff indicated she no longer needed them. The facility's policy required an interdisciplinary assessment and consent, which were not followed, leading to the deficiency.
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications, lacking adequate monitoring for antiplatelet use and side effect monitoring for anticonvulsants. One resident's records did not reflect necessary diagnoses for several medications, while another resident's records lacked appropriate diagnoses for Aricept and Aspirin. Staff interviews revealed deficiencies in monitoring and documentation procedures.
The facility failed to ensure adequate behavior and side effect monitoring for two residents prescribed psychotropic medications, including Sertraline, Buspirone, and Venlafaxine. This lack of documentation could hinder the assessment of medication effectiveness and safety. Interviews with staff highlighted the importance of monitoring, which was not consistently performed as per facility policy.
Two residents in a LTC facility experienced significant medication errors. A resident with GERD was not given Protonix before meals as required, affecting its effectiveness. Another resident with hypotension received Midodrine despite blood pressure readings exceeding prescribed parameters, risking hypertension. Staff interviews revealed non-compliance with physician orders and medication administration guidelines.
A resident's request for an alternate meal was not honored until a state surveyor intervened. The resident, who was cognitively intact and had a history of mental health disorders, had requested a deli sandwich instead of the spaghetti served. The Dietary Manager did not confirm the resident's meal preference and adhered strictly to the menu choices circled by residents, leading to dissatisfaction and potential negative outcomes. The facility's policy on accommodating food preferences was not followed, as residents were often restricted to their pre-selected menu items.
A facility failed to maintain effective infection control practices during incontinent and urinary catheter care for a resident with cognitive impairment and a history of infection. The RCP did not perform proper hand hygiene or glove changes, and placed a contaminated plastic bag on the resident's mattress. The resident had an indwelling catheter and pressure ulcers, increasing the risk of infection. Staff interviews revealed a lack of training and competency evaluations for the RCP.
The facility failed to obtain informed consent for psychoactive medications for three residents. One resident received Sertraline without a completed consent form, while another's consent for Seroquel lacked a written signature, and the resident was unaware of the medication's purpose. A third resident's consent for Zyprexa was incomplete, with no written signature. Staff interviews revealed confusion and inconsistencies in the consent process, risking uninformed administration of medications.
A resident with multiple medical conditions, including a deep tissue injury on the right heel, did not receive wound care as per physician's orders. The nurse applied Medihoney instead of betadine and wrapped the resident's foot incorrectly, contrary to the specified care plan. This failure to follow orders could lead to wound deterioration and infection.
A resident with an indwelling urinary catheter was found without a securement device, contrary to facility orders, increasing the risk of infection. During care, a CNA failed to change gloves after handling multiple items, further risking contamination. Interviews with staff confirmed these actions were against facility policies, highlighting deficiencies in catheter care and infection control.
A facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP). An RN did not wear protective equipment while completing wound care on a resident, and a CNA failed to change gloves and wear a gown during urinary catheter care for another resident. These actions risked cross-contamination and infection spread, as confirmed by facility leadership.
Delay in Obtaining and Reporting STAT X-ray Results
Penalty
Summary
The facility failed to provide or obtain radiology and other diagnostic services to meet the needs of a resident who required a STAT x-ray. The resident, an elderly female with multiple diagnoses including dementia, multiple sclerosis, and osteopenia, complained of right knee pain and swelling. A STAT x-ray was ordered by the nurse practitioner and performed the same day, with results indicating a nondisplaced lateral plateau fracture and a distal fibular fracture. However, the facility did not review or act upon the x-ray results until four days after the imaging was completed. During this period, the x-ray results were available in the facility's electronic portal, but staff did not access or communicate the findings to the physician in a timely manner. Interviews revealed that staff were unclear about the timeframes for STAT orders and did not consistently follow up on pending results. The Director of Nursing was out of town and assumed the radiology company had resolved a missing diagnosis code, but no further follow-up occurred until she personally checked the portal days later. The 24-hour report sheets and progress notes did not reflect ongoing monitoring or follow-up regarding the x-ray results or the resident's knee condition during this interval. The delay in reviewing and reporting the STAT x-ray results led to a delay in treatment for the resident's fractures. Staff interviews indicated a lack of clear communication and handoff regarding the pending diagnostic results, and the facility's policy required timely notification of results to the physician. The resident continued to experience pain, though it was managed with medication, and there was no documentation of complications during the delay.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Resident Injured Due to Unlocked Bed During Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including chronic obstructive pulmonary disease, peripheral vascular disease, and an above-the-knee amputation, was injured during incontinent care. The resident, who had moderate cognitive impairment and required substantial assistance for mobility and hygiene, was being assisted by an LVN. During the care, the LVN raised the bed and attempted to roll the resident, but the bed was not properly locked. As a result, the bed rolled into the wall, causing the resident to strike the wall with her foot, head, and left hand. Following the incident, the resident sustained multiple injuries, including fractures to the second and third metatarsals of the left foot and a distal ulna fracture in the left wrist, as confirmed by X-rays and orthopedic evaluation. Additional injuries included bruising and abrasions to both hands, a skin tear to the left hand, and redness and bruising to the left side of the forehead. The resident and her family reported that the injuries were a direct result of the bed rolling during care, and the LVN acknowledged that he believed the bed was locked but it still moved when he leaned against it. Interviews with facility staff revealed that the bed had six brakes, with only one found to be loose, and no mechanical reason was identified for the bed's movement if the brakes were properly engaged. The facility's policies on bed safety and resident safety did not specifically address the requirement to lock beds during incontinent care. The incident led to the resident requiring two-person assistance for future care, but the deficiency was due to the failure to ensure the bed was locked and the environment was free from accident hazards during care.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within the required two-hour timeframe for one resident. A resident with schizoaffective disorder, diabetes, and hypertension, who had a history of verbal aggression and moderate cognitive impairment, alleged that a staff member threw a blanket at her face and told her to "shut the hell up." The incident was reported by the resident to a restorative care partner (RCP), who then informed an LVN. The LVN subsequently reported the allegation to the Social Worker, but none of these staff members reported the incident directly to the Abuse Coordinator (EDO) as required by facility policy. Interviews and record reviews revealed that the LVN and Social Worker did not recognize the incident as an abuse allegation and failed to notify the Abuse Coordinator immediately. The LVN stated she did not report the incident to the EDO because the EDO was not present in the facility at the time, and instead reported it to the Social Worker. The Social Worker also did not report the allegation to the EDO, stating she misunderstood the nature of the report and did not realize it was an abuse allegation until later. The delay in reporting resulted in the Abuse Coordinator learning of the incident approximately three hours after the initial allegation was made to staff. Documentation confirmed that the facility's policy required all events involving allegations of abuse to be reported immediately or within two hours. The failure of multiple staff members to follow this policy led to a delay in the investigation and intervention. The resident involved was not injured and did not express fear of living in the facility, but the delay in reporting the allegation constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Immediate Wound Care Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically regarding wound care treatment. The resident, a female with multiple medical conditions including acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, was admitted without appropriate wound care orders. Despite having multiple areas of shearing and pressure ulcers, the facility did not initiate wound care treatment until several days after admission, leading to a delay in care. Upon admission, the resident had several pressure ulcers, including on the right hip, right thigh, and left thigh, which were not addressed with immediate wound care orders. The facility's records indicated that the resident's wounds were not properly assessed or treated in a timely manner, and there was a lack of documentation regarding the initiation of wound care. The facility's staff, including the admitting nurse and other clinical staff, failed to obtain or implement necessary wound care orders, resulting in a lack of appropriate treatment for the resident's pressure ulcers. Interviews with facility staff revealed a lack of communication and understanding of the procedures for obtaining and implementing wound care orders. The admitting nurse did not receive a timely response from the nurse practitioner regarding wound care, and there was confusion among staff about the resident's wound care needs. Additionally, the facility did not provide the resident with a specialty mattress or pressure-relieving devices, further contributing to the inadequate care of the resident's pressure ulcers.
Removal Plan
- Resident #93 had wound care orders written.
- A weekly wound assessment was completed.
- A specialty mattress was placed on Resident #93's bed.
- Resident #93's heels were floated.
- Skin sweep completed to ensure all skin issues were identified and had current orders and interventions in place.
- Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders.
- If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult.
- All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted.
- Education will also include the completion of weekly skin assessments per schedule.
- All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift.
- Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor.
- Ad hoc QAPI meeting will be held with the Medical Director reviewing the policies and procedures for wound care.
- All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation by the Director of Clinical Education or designee.
- All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.
- Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds.
- Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.
- Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.
- Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly.
- The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment and care. One resident was admitted with multiple stage 3 pressure ulcers but did not receive timely wound care treatment or a specialty mattress as per the facility's policy. The resident's weekly skin assessments were not performed as scheduled, and the facility did not implement necessary interventions such as repositioning and offloading to prevent further skin breakdown. Another resident did not have documented wound care on several occasions, and their weekly skin assessments were also not recorded as required. This lack of documentation raises concerns about whether the necessary care was provided to prevent the deterioration of existing wounds or the development of new ones. A third resident also experienced a lack of documented wound care and weekly skin assessments. The facility's failure to adhere to professional standards of practice and its own policies for wound care and prevention placed residents at risk for further wound deterioration and development. The facility's staff did not consistently follow through with wound care orders, and there was a lack of communication and documentation regarding the residents' wound care needs.
Removal Plan
- Resident #93 had wound care orders written.
- A weekly wound assessment was completed.
- A specialty mattress was placed on Resident #93's bed.
- Resident #93's heels were floated.
- Skin sweep completed to ensure all skin issues were identified and had current orders and interventions in place.
- Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders.
- If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult.
- All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted.
- Education will also include the completion of weekly skin assessments per schedule.
- All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift.
- Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor.
- Ad hoc QAPI meeting will be held with the Medical Director reviewing the policies and procedures for wound care.
- All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation by the Director of Clinical Education or designee.
- All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers.
- Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds.
- Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion.
- Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely.
- Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly.
- The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months.
Failure to Conduct Annual Competency Evaluations for RCPs
Penalty
Summary
The facility failed to conduct annual competency evaluations for five Resident Care Providers (RCPs), identified as RCP L, RCP O, RCP U, RCP V, and RCP W. These evaluations are crucial to ensure that the RCPs are proficient in the care they provide to residents. The personnel file review revealed that none of these RCPs had a competency evaluation on file, despite their hire dates being over a year prior. This oversight was discovered during a record review conducted on February 12, 2025. Interviews with the Director of Nurses and the Administrator revealed a lack of awareness regarding the completion of these evaluations. The Director of Nurses admitted to not knowing if the evaluations had been completed and could not locate them, suggesting that the previous Director of Nurses might not have filed them properly. The Administrator also expressed uncertainty about the completion of the evaluations, although she believed they had been done. The facility's policy requires all nursing staff to meet specific competency requirements and participate in a competency-based staff development program, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #1, who had a history of falls and a fracture prior to admission, experienced an actual fall and unplanned weight loss, yet these issues were not included in her care plan. Additionally, her risk of pressure ulcers, pain management, and use of antiplatelet medication were not addressed in her care plan, despite being triggered in her MDS assessment. Resident #11, who was on an antiplatelet medication, did not have this medication reflected in her care plan, even though it was part of her physician's orders and medication administration record. This oversight indicates a lack of coordination between the resident's medical needs and the care planning process, potentially impacting her overall care and well-being. Resident #15, who required Enhanced Barrier Precautions due to an indwelling catheter, did not have the necessary signage posted in her room as per her care plan intervention. This failure was observed over multiple days, and staff interviews revealed a lack of clarity regarding responsibility for care plan updates and implementation. The absence of the Enhanced Barrier Precaution sign could lead to inadequate infection control measures, posing a risk to the resident and others in the facility.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by observations, interviews, and record reviews. Resident #18's oxygen concentrator was missing a filter, and the air intake area was covered with gray fuzzy and hair-like particles. Despite an order to clean or change the oxygen concentrator filters every Sunday night shift, the documentation indicated that the task was completed, but observations showed otherwise. Resident #18, who had a history of cerebrovascular disease and moderate cognitive impairment, was observed multiple times without her oxygen, and the concentrator remained in a poor state. Resident #24's oxygen concentrator filter was also covered in gray fuzzy and hair-like particles, and there was no order to clean or change the filters. Despite the resident's use of oxygen therapy for heart failure and dementia, the facility did not ensure the equipment was maintained properly. Interviews with staff revealed a lack of awareness and responsibility for maintaining the oxygen concentrator filters, which placed the resident at risk for respiratory infections. Resident #22's oxygen concentrator filter had white fuzzy particles, and the resident was not on the ordered number of liters of oxygen. Additionally, the resident's nebulizer mask was not stored in a bag when not in use, increasing the risk of infection. The facility's documentation was inconsistent, with missing entries for oxygen use and medication administration. Resident #38's oxygen concentrator filter was also dirty, and the nasal cannula tubing was not stored properly. Interviews with staff highlighted confusion over responsibilities for maintaining the oxygen equipment, contributing to the deficiencies observed.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for two residents. Resident #1 did not receive several medications, including Atorvastatin, Cannabidiol, Lamotrigine, Sertraline, Minocycline, and Topiramate, on multiple occasions throughout January 2025. These medications were crucial for managing conditions such as hyperlipidemia, epilepsy, depression, and bacterial infections. The absence of these medications was documented in the Medication Administration Record (MAR) with a code indicating the need to see progress notes, which often cited awaiting pharmacy delivery or being on order. Resident #15 also experienced similar issues with medication availability. Medications such as Amiodarone, Aricept, Aspirin, Calcitriol, Cozaar, Lokelma, Carvedilol, Macrobid, and Miconazole were not administered on several dates due to them being on order or awaiting delivery. These medications were essential for managing conditions like abnormal heart rhythm, dementia, hypertension, hypocalcemia, and urinary tract infections. The MAR entries for these medications frequently indicated they were on order or awaiting pharmacy delivery, with some entries lacking documentation for the reason medications were not administered. Interviews with facility staff revealed systemic issues in the medication ordering process. The Licensed Vocational Nurse (LVN) and Assistant Director of Clinical Operations (ADCO) indicated that medications should be ordered well in advance, but there were delays due to various reasons, including pharmacy processing times and communication issues with family members responsible for certain prescriptions. Additionally, there were problems with the electronic ordering system and the pharmacy's operational hours, which contributed to the missed doses. The facility's policy required timely ordering and receiving of medications, but these procedures were not effectively followed, leading to the deficiencies observed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs and preferences. The resident, who had severe morbid obesity, reduced mobility, and a history of cerebrovascular disease, was observed multiple times with the call light placed out of reach on her paralyzed left side. This placement made it impossible for her to use the call light to request assistance, as she had no use of her left side. Interviews with staff members, including RCPs and LVNs, revealed that it was the responsibility of all staff to ensure that call lights were within reach of residents, especially those who were dependent on staff for assistance. Staff acknowledged that the call light should not be placed on the resident's paralyzed side and that failing to ensure the call light was accessible could lead to the resident feeling upset, helpless, and frustrated. Despite this understanding, the call light was repeatedly found out of reach during observations. The facility's policy on bedrooms, which was provided upon request, did not address the specific need for call lights to be within reach of residents. Interviews with various staff members, including the EDO and DCO, confirmed that ensuring call lights were accessible was a shared responsibility among all staff members. The deficiency was identified through observations and interviews, highlighting a failure to accommodate the resident's needs adequately.
Failure to Update PASRR for Resident with New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental health disorder received an accurate Preadmission Screening and Resident Review (PASRR) following a new diagnosis of Bipolar Disorder. The resident, who was initially admitted to the facility with no evidence of mental illness, was diagnosed with Bipolar Disorder in May 2023. However, the facility did not update the resident's PASRR status to reflect this new diagnosis, which could have impacted the resident's access to necessary assessments and specialized services. Interviews and record reviews revealed that the MDS Coordinator, who was responsible for updating the PASRR, did not complete the necessary documentation to capture the new diagnosis. The previous MDS nurse had added the diagnosis of Bipolar Disorder but failed to update the Mental Illness/Dementia Resident Review or the PL1 form. This oversight was acknowledged by the facility's staff, including the ADCO and EDO, who recognized that the resident might have missed out on services they qualified for due to the lack of timely updates to the PASRR documentation.
Inaccurate PASRR Level I Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's mental health diagnoses. The resident, who was admitted to the facility with diagnoses of Major Depressive Disorder, Schizoaffective Disorder, and Bipolar Disorder, was incorrectly marked as not having a mental illness on the PASRR Level 1 screening. This discrepancy was identified during a review of the resident's records, which showed that the PASRR Level 1 screening did not align with the resident's documented mental health conditions. Interviews with facility staff, including the MDS Coordinator and the Director of Nurses, revealed that the responsibility for completing the PASRR evaluations accurately lies with the MDS Coordinator. The Director of Nurses acknowledged that the resident's mental health conditions should have qualified for a positive PASRR Level 1 evaluation. The facility's policy on PASRR, dated November 2023, outlines the procedures for obtaining and completing PASRRs, but the failure to adhere to these procedures resulted in the resident not being properly assessed for needed services.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to a resident and/or their representative within 48 hours of admission. A resident, who was admitted with acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, did not receive a copy of the summary of the baseline care plan. The resident reported that a staff member began the baseline care plan upon admission but did not complete it due to being busy, and no one returned to finish it. The resident expressed a desire to have a copy of the care plan, which was not provided. Interviews with various staff members revealed confusion and lack of clarity regarding the responsibility for completing and distributing the baseline care plan. The ADCO mentioned that the admitting nurse could start the care plan, but it was unclear who was responsible for providing the summary to the resident. The EDO and DCO from a sister facility also provided conflicting information about the process and responsibilities. The facility's policy stated that the baseline care plan must be completed within 48 hours and a summary provided to the resident, but this was not adhered to in this case.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, specifically in the areas of oral care and bed baths. Resident #93, a female with acute kidney failure, urinary tract infection, morbid obesity, and stage 3 pressure ulcers, did not receive oral care or bed baths as required. Despite being admitted to the facility less than 21 days ago, the resident reported not receiving any bed baths or oral care since her admission. Observations confirmed that the resident's personal hygiene items, including a toothbrush and wash basin, appeared unused. Interviews with staff revealed a lack of adherence to the facility's protocols for providing ADL care. Licensed Vocational Nurse (LVN) D and Resident Care Provider (RCP) H acknowledged that the resident required moderate to extensive assistance with bathing and oral care, yet these services were not provided. RCP H admitted to not offering oral care or bed baths to the resident and was unsure of the frequency of hair washing required for the resident. The Director of Clinical Operations (DCO) and other staff members confirmed that oral care should be provided every shift and bed baths should occur three times a week, but these standards were not met for Resident #93. The facility lacked a specific policy on ADL care related to bathing and oral care, contributing to the oversight in providing necessary services to Resident #93. Staff interviews highlighted the importance of ADL care for maintaining hygiene, preventing infections, and ensuring residents' dignity and quality of life. The failure to provide these services could lead to poor hygiene, skin breakdown, and a negative impact on the resident's well-being.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to potential risks. One resident, who was cognitively intact, was found with a bottle of isopropyl 91% rubbing alcohol in his room, which he used on his skin. The resident was unaware of how he obtained the alcohol. Facility policy prohibits residents from keeping rubbing alcohol in their rooms due to the risk of accidental ingestion and poisoning. Interviews with staff confirmed that residents should not have access to rubbing alcohol, and it was against facility policy. Another resident, who was severely cognitively impaired, had exposed electrical wiring in his room. The resident was dependent on assistance for activities of daily living due to his medical conditions, including bipolar disorder and chronic inflammatory demyelinating polyneuritis. Staff interviews revealed that exposed wiring should be reported and repaired to prevent potential harm. The facility's policy requires incidents and accidents to be investigated and reported, but the presence of exposed wiring indicates a lapse in adherence to these safety protocols.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to potential risks of urinary tract infections (UTIs) and other complications. Resident #10, who had a history of cognitive impairment and was dependent on staff for toileting hygiene, did not receive proper incontinent and urinary catheter care. During an observation, RCP O did not perform hand hygiene or change gloves appropriately while providing care, and failed to clean the resident's perineum area or urinary catheter insertion site effectively. The plastic bag used for soiled washcloths was repeatedly placed on the resident's bed after falling on the floor, posing an infection control issue. Interviews with staff revealed a lack of competency evaluations and training for RCP O, contributing to the improper care provided. Resident #15, who had an indwelling catheter due to neurogenic bladder, was found without a securement device for the catheter on multiple occasions. The absence of a securement device increased the risk of catheter dislodgement and potential injury. Despite physician orders and care plans indicating the need for securement devices, observations and interviews confirmed that the resident did not have the device in place, and staff failed to ensure its use. The lack of securement was not documented, indicating a failure in the facility's monitoring and documentation processes. Resident #22 also experienced inadequate catheter care, with missing documentation of catheter care on several dates. The resident reported that catheter care was not provided daily, and observations showed cloudy urine, suggesting potential infection. The securement device for the catheter was not in place, as confirmed by the resident and staff interviews. The facility's policies on catheter care and hand hygiene were not followed, leading to increased risks of infection and discomfort for the residents involved.
Failure to Maintain Nutritional Parameters and Monitor Weight
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to a deficiency in care. The resident, who had a history of Asperger's syndrome, epilepsy, a displaced bimalleolar fracture, and osteoarthritis, was not weighed weekly as required upon admission and readmission. The facility did not obtain the resident's weight after her readmission from a hospital stay, which was crucial for establishing a new baseline. Additionally, the facility did not follow the dietary recommendation to change the resident's health shakes to house shakes for 90 days, which was intended to address weight concerns. The resident's medical records indicated a significant weight loss of 13.4% over 30 days, yet the facility's care plan did not reflect this unplanned weight loss. The facility's failure to document and monitor the resident's weight as per the established guidelines and dietary recommendations contributed to the deficiency. Interviews with facility staff revealed a lack of clarity and coordination regarding responsibilities for obtaining and documenting weights and implementing dietary recommendations. The facility's Weight Surveillance Program policy required weekly weights for new admissions and readmissions, but this was not adhered to in the resident's case. Staff interviews highlighted that the dietary recommendations were not accurately transcribed or followed, which could have helped in addressing the resident's weight loss. The deficiency was further compounded by the absence of a clear assignment of responsibilities among the staff for monitoring and implementing dietary interventions.
Failure to Follow Bed Rail Protocols for Resident
Penalty
Summary
The facility failed to adhere to proper procedures before installing bed rails for a resident, leading to a deficiency. The resident, a female with a history of Asperger's syndrome, epilepsy, a displaced bimalleolar fracture, and osteoarthritis, was admitted to the facility and required supervision and assistance for various mobility tasks. Despite these needs, the facility did not attempt alternative measures before installing bed rails, nor did they obtain informed consent from the resident or her representative prior to installation. Additionally, the facility did not conduct a bed rail assessment to evaluate the risk of entrapment for the resident. Observations revealed that the resident had assist bars on both sides of her bed, which she sometimes used for repositioning. However, interviews with staff indicated that the resident no longer needed the assist rails, as she refused to get out of bed and had limited safety awareness. The lack of a proper assessment and informed consent posed a potential safety risk to the resident. The facility's policy required an interdisciplinary assessment and consultation with the attending physician before using side rails, as well as obtaining consent from the resident or their legal representative. However, these steps were not followed, and the resident's care plan and medical records did not reflect the use of assist rails or an assessment for entrapment risk. Interviews with various staff members highlighted inconsistencies in the process of ordering, assessing, and maintaining bed rails, contributing to the deficiency.
Failure to Monitor and Document Medication Use
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary medications. Specifically, the facility did not provide adequate monitoring for the use of antiplatelet medications for both residents. Additionally, one resident did not have side effect monitoring for anticonvulsant use, and there were no documented diagnoses for several medications prescribed to this resident, including Lamotrigine, Levothyroxine, Minocycline, Ondansetron, Sertraline, and Topiramate. For the first resident, the facility's records did not reflect the necessary diagnoses for the prescribed medications, nor did they include monitoring for the use of an antiplatelet or side effect monitoring for anticonvulsant use. This resident had a history of epilepsy, major depressive disorder, anxiety disorder, and hypothyroidism, and was receiving multiple medications without proper documentation or monitoring. The second resident's records also lacked appropriate diagnoses for medications such as Aricept and Aspirin. The facility did not ensure monitoring for the use of an anticoagulant, and the resident's care plan did not reflect the use of an antiplatelet. Interviews with facility staff revealed a lack of understanding and implementation of proper monitoring and documentation procedures for these medications.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #1, a female with diagnoses including Asperger's syndrome, epilepsy, major depressive disorder, and anxiety disorder, was prescribed Sertraline, an antidepressant. However, there was no documentation of behavior and side effect monitoring for this medication, which is crucial for assessing the medication's effectiveness and safety. Similarly, Resident #11, a female with diagnoses including cerebral infarction, type 2 diabetes, depression, and anxiety disorder, was prescribed Buspirone for anxiety and Venlafaxine for depression. The facility did not document behavior monitoring for these medications, which is necessary to justify their use and ensure they are achieving the desired therapeutic outcomes without adverse effects. Interviews with facility staff, including an LVN, the ADCO, and the EDO, revealed that behavior and side effect monitoring should be documented on each shift for residents on psychotropic medications. The lack of such documentation could prevent the identification and treatment of side effects or ineffective medication use. The facility's policy emphasizes the importance of monitoring psychotropic drug use and conducting regular reviews to assess the necessity and appropriateness of these medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #1, who has a history of Asperger's syndrome, muscle weakness, and constipation, was prescribed Protonix for GERD. The medication was not scheduled to be administered before meals as required for optimal effectiveness. Instead, it was given at 9 a.m., which is not ideal for the medication's intended therapeutic effect. Observations noted that Resident #1 did not respond to greetings, and attempts to contact her responsible party were unsuccessful. Resident #93, who was admitted with acute kidney failure and hypotension, was prescribed Midodrine to treat low blood pressure. The medication was to be held if the resident's blood pressure exceeded certain parameters and was to be administered with meals. However, the medication was given even when the resident's blood pressure was above the ordered parameters on multiple occasions. Interviews with staff revealed a lack of adherence to the physician's orders, with the medication being administered outside the specified conditions, potentially placing the resident at risk for hypertension or stroke. Interviews with various staff members, including LVNs and the ADCO, highlighted a lack of compliance with medication administration guidelines. Staff acknowledged the errors and the importance of following physician orders, including the timing of medication administration and adherence to hold parameters. The facility's policy on medication administration emphasizes the need for medications to be given as prescribed, yet these guidelines were not followed, leading to the deficiencies noted in the report.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically for Resident #17, who was cognitively intact and had a history of bipolar disorder, major depressive disorder, and anxiety disorder. On the date in question, Resident #17 had requested an alternate meal choice for lunch, which was not honored until a state surveyor intervened. The resident had circled only vegetables and dessert on her menu and had verbally requested a deli sandwich, which was not communicated to the dietary staff. The Dietary Manager did not confirm with the resident if she had accidentally omitted a main meal item and instead served her spaghetti, which she did not like. Interviews revealed that the Dietary Manager typically adhered strictly to the menu choices circled by residents and did not accommodate changes unless there was time and food available. The Dietary Manager's approach was perceived as inflexible by both the resident and staff, with the Dietary Manager reportedly acting as if the food budget was her personal expense. This rigidity in accommodating food preferences was highlighted by a previous incident where the resident was initially denied oatmeal, which she had not marked on her menu but later received after some delay. The facility's policy on resident food preferences indicates that individual preferences should be assessed and accommodated, with a variety of foods offered at each meal. However, the Dietary Manager's actions did not align with this policy, as residents were often restricted to their pre-selected menu items. This failure to honor food preferences could potentially lead to decreased food intake and other negative outcomes for residents, as noted by the ADCO and DCO during their interviews.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene and glove use by a Resident Care Provider (RCP) while providing incontinent and urinary catheter care to a resident. The RCP did not perform hand hygiene after changing gloves and failed to clean the resident's perineum area or urinary catheter insertion site properly. This lack of proper hygiene practices could lead to cross-contamination and increase the risk of infection for the resident. The resident involved had a history of infection, cognitive impairment, and was dependent on staff for toileting hygiene. She had an indwelling urinary catheter and was always incontinent of bowel, with a stage 3 pressure ulcer and moisture-associated skin damage. During the care process, the RCP placed a plastic bag on the resident's low air loss mattress, which fell onto the floor multiple times. The RCP picked up the bag and placed it back on the mattress without changing gloves or performing hand hygiene, further compromising the resident's environment. Interviews with facility staff revealed that the RCP had not received proper training or competency evaluations for incontinent and urinary catheter care. The Director of Resident Accounts and other staff members acknowledged the infection control issues and the lack of proper training and documentation. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, contributing to the deficiency in infection control practices.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychoactive medications. For one resident, the facility did not complete the psychoactive medication therapy consent upon admission and prior to administering Sertraline, an antidepressant. Despite the medication being prescribed and administered, there was no record of a consent form, and the facility staff could not locate it. Interviews with staff revealed a lack of clarity on who was responsible for obtaining the consent, and it was acknowledged that the absence of consent placed the resident and their family at risk of not being informed about the medication's risks and benefits. Another resident's consent for antipsychotic medication, Seroquel, was not properly documented. The consent form lacked a written signature, and the resident reported not being informed about the medication's purpose or side effects. The resident expressed uncertainty about the medication's use and did not recall giving verbal consent. Staff interviews indicated that verbal consent was noted without proper documentation, and there was confusion about the process for obtaining and recording consent. A third resident's consent for Zyprexa, another antipsychotic medication, was also incomplete, with no written signature from the resident or their representative. The resident was unwilling to discuss their medication, and attempts to contact their representative were unsuccessful. Staff interviews highlighted inconsistencies in the process of obtaining consent, with some staff unsure of the requirements and others acknowledging the importance of informed consent to ensure residents and their representatives understood the medication's risks and benefits. The facility's policies and state regulations emphasize the necessity of informed consent, which was not adhered to in these cases.
Deficiency in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound management. The resident, who had multiple medical conditions including diabetes, peripheral vascular disease, and pressure-induced deep tissue injury (DTI) on the right heel, did not receive wound care as per the physician's orders. The orders specified that the right heel should be cleansed with normal saline, patted dry, and painted with betadine, but instead, Medihoney was applied, which was not suitable for the condition of the wound. The nurse responsible for the wound care, RN E, had only been working at the facility for two weeks and was not familiar with the residents. During an observation, RN E was seen applying Medihoney to the right heel instead of betadine, and wrapping the resident's right foot with gauze and elastic wrap incorrectly. This was contrary to the physician's orders, which required the right heel to be left open to air and the legs to be wrapped from the base of the toes to below the knees, avoiding pressure on the DTI. Interviews with the nurse practitioner, assistant director of nursing, and director of nursing confirmed that the incorrect application of Medihoney and improper wrapping could lead to the deterioration of the wound. The facility's policy on skin management emphasized the importance of following physician's orders to prevent and treat skin breakdown, but these were not adhered to, resulting in a risk of infection and impeded healing for the resident.
Failure in Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for a resident with urinary incontinence, specifically in the management of an indwelling urinary catheter. The resident, who was cognitively intact and required maximal assistance for toileting hygiene, had an indwelling catheter and was at risk for urinary tract infections due to obstructive uropathy. Despite having an order to ensure the catheter was secured to reduce friction and pulling, the resident was found without a catheter securement device during care, which was confirmed by the CNA providing care. During the provision of incontinent and catheter care, CNA A did not perform hand hygiene or change gloves appropriately, which could lead to contamination and increased risk of infection. CNA A handled multiple items in the resident's room before performing catheter care without changing gloves, which was acknowledged as a risk for spreading germs and causing infection. The CNA admitted to not changing gloves and recognized the increased risk of infection due to this oversight. Interviews with facility staff, including the ADON and DON, confirmed that the lack of a catheter securement device and improper glove use during catheter care were against facility policies and placed the resident at risk of infection. The DON acknowledged that the nurse should not have documented the presence of a securement device without visual confirmation. The facility's policies and CDC guidelines emphasize the importance of securing catheters and maintaining hygiene to prevent infections, which were not adhered to in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN E and CNA D, which did not adhere to the Enhanced Barrier Precautions (EBP) policy. RN E did not follow the EBP policy while performing wound care on a resident with a pressure ulcer on the right heel. After applying an adhesive dressing, RN E removed her gown and gloves and continued to wrap the resident's foot with gauze and an elastic wrap without wearing protective equipment, potentially risking the spread of infection. RN E admitted to not being fully informed about the EBP requirements and acknowledged the mistake during an interview. CNA D also failed to adhere to the EBP policy while providing urinary catheter care to another resident. CNA D did not wear a gown and failed to change gloves after cleaning the resident's catheter, subsequently touching various items in the resident's room, including the catheter securement device, bedding, and catheter drainage bag. This oversight was acknowledged by CNA D, who admitted to forgetting the proper procedure and recognized the risk of cross-contamination and infection spread. Interviews with the facility's ADON, DON, and ADM confirmed that both RN E and CNA D did not follow the facility's infection control policies. The ADON and DON highlighted the importance of using gowns and gloves during high-contact care activities to prevent the spread of infection. The ADM emphasized the expectation for staff to adhere to infection control policies and acknowledged the potential risk of infection due to the staff's failure to follow the EBP guidelines.
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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