Focused Care At Mount Pleasant
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Texas.
- Location
- 1606 Memorial Ave, Mount Pleasant, Texas 75455
- CMS Provider Number
- 455900
- Inspections on file
- 39
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 26 (2 serious)
Citation history
Health deficiencies cited at Focused Care At Mount Pleasant during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had a discontinued order for Meloxicam 7.5 mg, with two full blister cards (60 tablets) remaining on the med cart. A medication aide brought the cards to an RN, who confirmed in the EMR that the drug was discontinued and stated she would handle it, but did not secure the medication in the locked discontinued box as per facility policy. Later, during a police traffic stop, officers found the two full blister cards of the resident’s Meloxicam in the RN’s car, and the RN acknowledged having the medication, leading to a finding that the resident’s property had been misappropriated.
Three residents did not have accurate or updated care plans reflecting their current needs and conditions. One resident's pressure ulcer was not care planned for several weeks after re-admission, another was listed as having a wander guard in the care plan despite not wearing one, and a third was documented as residing on a secured unit even after being moved to a regular room. Staff interviews revealed confusion over responsibility for care plan updates, leading to discrepancies between documentation and actual care.
A resident at risk for skin breakdown did not receive weekly skin assessments by nursing staff as required by facility policy and the care plan. For several consecutive weeks, only CNA-completed shower sheets were available instead of nurse-conducted assessments, despite the resident's medical conditions and risk factors.
A resident with an indwelling Foley catheter and recent UTI was observed with the catheter drainage bag lying on the floor, contrary to facility policy and care plan interventions. Staff interviews confirmed that all were responsible for ensuring catheter bags were kept off the ground, but this was not done, resulting in a deficiency in catheter care and infection prevention.
The facility failed to ensure accurate documentation of wound assessments for two residents, with the Treatment Nurse's records not matching the Wound Care NP's findings that pressure ulcers were worsening. Both residents had significant medical histories and were receiving ongoing wound care, but discrepancies in documentation were identified and acknowledged by staff. The facility did not have a policy on documentation accuracy.
A resident with Alzheimer's, schizophrenia, and anxiety, who exhibited wandering and cognitive deficits, became agitated after a minor incident with another resident. An LVN intervened by yelling at the resident and instructing him to "sit his ass down," which was witnessed by staff and confirmed by the LVN. This conduct did not meet the facility's policy requiring staff to treat residents with dignity and respect.
A resident was re-admitted with a pressure ulcer that was documented in nursing notes and reported to the MDS Nurse, but the ulcer was not recorded on the MDS assessment. The MDS Nurse acknowledged missing the wound despite available information, resulting in an inaccurate assessment.
The facility did not maintain an effective pest control program, resulting in ongoing cockroach and water bug infestations in several resident rooms. Multiple residents with chronic health conditions reported frequent pest sightings, and staff interviews confirmed that pest sightings were common but not properly documented or communicated. The contracted exterminator was not informed of problem areas due to lack of logbook entries, and pest control measures were not effectively implemented.
Surveyors identified multiple deficiencies in food storage and kitchen maintenance, including unlabeled and undated food items, rotting potatoes, improper storage of a scoop in a sugar bin, and significant disrepair in the pantry and kitchen ceiling. Air conditioning vents were found to be dirty and dripping condensation, with unclear staff responsibility for cleaning and maintenance. Facility policy required proper food labeling, storage, and sanitation, but these standards were not consistently followed.
The facility did not maintain a kitchen freezer in safe operating condition, as evidenced by repeated observations of unsafe internal temperatures and thawed food items. Staff interviews revealed ongoing issues with the freezer's door, thermometer, and fans, and temperature logs did not accurately reflect the actual conditions. This failure resulted in food being stored at unsafe temperatures, contrary to facility policy.
Several residents with varying medical conditions reported that meals were consistently cold, lacked flavor, and were repetitive, with insufficient portion sizes and unappealing vegetables. Staff interviews confirmed frequent complaints about food quality, and resident council minutes documented ongoing dissatisfaction with meal temperature, taste, and variety. Observations and meal sampling further supported these findings, indicating the facility did not meet its own standards for preparing and serving food.
A nurse failed to wear a gown while administering medications and tube feeding to a resident on enhanced barrier precautions for a g-tube, despite facility policy and care plan requirements. The nurse was unaware of the resident's EBP status and did not see the posted signage or available PPE, resulting in a breach of infection control protocols.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
A resident with cognitive impairment and a history of wandering was physically assaulted by another resident with a history of aggression, who struck him multiple times with a wheelchair foot pedal. The attack caused multiple lacerations and a worsening subdural hematoma, requiring emergency medical intervention. The incident occurred after the injured resident had already returned from the ER for a previous fall, and was discovered by an LVN who was the only staff member present in the secured unit at the time.
Two residents with severe cognitive impairment and behavioral issues were involved in separate incidents where one was assaulted by another resident with a wheelchair pedal, resulting in a worsened subdural hematoma, and another experienced an unwitnessed fall from a wheelchair, leading to a nasal fracture. Both incidents occurred when only one staff member was present or staff were not aware of each other's absence, and the facility lacked a specific policy for supervision or staffing on the secured unit.
A facility failed to maintain accurate records and reconciliation of controlled substances, resulting in the unaccounted loss of 55 tablets of Hydrocodone prescribed to a resident with severe cognitive impairment and chronic pain. Inconsistent narcotic counts and lack of proper documentation during a unit transfer contributed to the inability to account for the medication.
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving physical altercations between residents with cognitive impairments. One resident struck another with a cup during a dining room altercation, while another resident was hit in the cheek after a misunderstanding about room ownership. A third incident involved a resident being struck in the upper body during a verbal disagreement. Despite interventions by staff, these incidents highlight a deficiency in maintaining a safe environment.
A resident with Alzheimer's and PTSD was verbally and physically abused by an LVN, resulting in the resident being pushed and falling. The incident was witnessed by a CNA who reported that the LVN made derogatory comments before pushing the resident. The resident, who had a history of falls and required supervision, was not protected from abuse as per the facility's policy.
A resident's privacy was breached when an LVN recorded him during an emergent situation without consent and shared the video with an RN, who further distributed it. The resident, with a history of heart failure and anxiety, was not informed of the recording, leading to emotional distress. The facility failed to report the incident promptly, contributing to a deficiency in maintaining resident privacy.
A resident with severe medical conditions was incorrectly documented as Full Code, leading to unwanted CPR. The facility failed to verify the resident's DNR status with the family, resulting in an Immediate Jeopardy situation. Additionally, the facility lacked a system to track CPR certifications for nursing staff.
The facility failed to ensure informed consent for psychotropic medications for a resident and two other residents. A resident received Trazodone without a signed consent form, while two other residents had incomplete consent forms for their medications. Staff interviews revealed a lack of oversight and training in completing these forms, and the facility's policy did not address the need for consent forms.
The facility failed to update comprehensive care plans for four residents, leading to discrepancies in documented care needs. A resident's care plan did not reflect hospice election, another's relocation was not updated, a third resident's oxygen therapy was omitted, and a fourth resident's discontinued antibiotic therapy and PICC line removal were not documented. Staff interviews revealed expectations for regular updates, yet these deficiencies indicate lapses in the process.
A facility reported a medication error rate of 73.08%, involving late administration and incorrect medication handling for three residents. A resident with multiple sclerosis received medications late due to staffing issues, another with diabetes had delayed insulin administration, and a third with schizophrenia received incorrect medication and ointment application.
The facility failed to provide sufficient support personnel for the food and nutrition service, leading to delayed meal service on multiple occasions. Observations and interviews revealed that lunch meals were served late due to staff turnover and lack of available help. The Dietary Manager and Administrator acknowledged the issue, citing mismanagement of time and inexperience in management roles. Despite expectations for timely meal service, the facility did not provide a policy on meal timing.
The facility's kitchen failed to meet professional food safety standards, with undated food items, unclean equipment, and improper storage practices observed. Staff interviews revealed lapses in adherence to cleaning protocols and food safety practices, including the use of expired test strips and lack of hair restraints. The Administrator confirmed expectations for food safety, but the facility's policies were not fully implemented, risking foodborne illness and contamination.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in urine specimen collection, catheter care, and dining room practices. A resident's urine specimen was potentially contaminated, and another resident did not receive proper catheter care, increasing the risk of infection. Additionally, a staff member was observed eating while serving meals, posing a cross-contamination risk.
A facility failed to implement an effective infection prevention and control program, as demonstrated by a resident with schizophrenia, multiple sclerosis, and parkinsonism who was not properly assessed for UTI criteria before antibiotic use. The resident's urine culture showed potential contamination, and the ADON admitted to not providing education on clean-catch urine collection. The DON and Assistant Administrator highlighted the lack of proper infection control measures and antibiotic stewardship, leading to the deficiency.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the main building, including the dining room and resident rooms. Observations showed flies landing on residents and their food, with staff acknowledging the issue but not taking effective measures. The facility's pest control policy was not properly implemented, contributing to unsanitary conditions.
A facility failed to ensure an arbitration agreement was explained to a resident's responsible party, who had severe cognitive impairment. The responsible party signed the agreement electronically without understanding it, as the facility did not review the admission packet with her. Staff interviews revealed inconsistencies in the process of explaining the agreement, and there was no policy in place regarding arbitration.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and a terminal diagnosis, resulting in inadequate end-of-life care. The DON was unable to locate hospice documentation or contact the hospice agency, leading to a lack of communication and understanding of care responsibilities. This deficiency posed a risk to the resident's continuity of care and emotional well-being.
The facility did not follow the scheduled breakfast menu, failing to provide sausage and waffles as planned. This was due to a miscalculation in inventory and a mix-up in the breakfast schedule. The Dietician Consultant and Dietary Manager confirmed the importance of menu adherence for nutritional value, and the Administrator acknowledged the need for system revision.
Two residents experienced significant medication administration delays due to staffing issues and nursing judgment. One resident with multiple health conditions received medications late, while another with diabetes had delayed insulin administration. The facility's policies require timely medication administration, which was not adhered to, leading to a noted deficiency.
A facility failed to maintain resident dignity during meal service when an LVN referred to residents needing feeding assistance as 'feeders.' This terminology was acknowledged as inappropriate by the LVN, DON, ADON, and Administrator, who emphasized the importance of using respectful language to avoid emotional harm. The facility's policy requires staff to address residents respectfully, by their name of choice.
A resident's medical records were not provided to his attorney within the required timeframe, despite multiple requests. The resident, with Alzheimer's and severe cognitive impairment, had his records requested in November, but they were only delivered in May. Interviews revealed confusion among staff about the records release process, contributing to the delay.
A facility failed to ensure a resident's advance directive was accurately documented, leading to conflicting code status records. The resident, with severe cognitive impairment, had a care plan indicating full code status, while a physician's order and OOH-DNR form indicated DNR status. The OOH-DNR form lacked a responsible party's signature, making it incomplete. Staff interviews revealed a lack of oversight in verifying DNR documentation.
The facility failed to provide a homelike dining environment in the men's secure unit by serving meals on trays during lunch. Observations showed LVN U left plates on trays, contrary to the facility's policy. The DON and ADON expected plates to be removed to maintain dignity, while the Administrator cited concerns about residents' cognition. The facility's policy emphasizes a homelike environment, which was not followed.
A resident with contractures did not receive appropriate treatment to prevent further decrease in range of motion. Despite the care plan indicating the need for a splint, there were no orders for its application, and the resident reported not having it applied since returning from the hospital. Staff interviews revealed confusion over responsibility for applying the splint, and the facility lacked a policy on contracture management.
Two residents with indwelling urinary catheters did not receive appropriate care to prevent urinary tract infections. A resident's catheter was not secured, increasing the risk of trauma and infection. Another resident's catheter care was improperly performed, with inadequate cleaning and glove changes, contributing to infection risk. Staff interviews revealed expectations for proper care were not met, particularly with contracted staff, leading to deficiencies in care.
A resident with Alzheimer's and obstructive uropathy was prescribed oxygen at 2-3 liters per minute but was observed receiving 3.5 liters per minute. Staff interviews confirmed the discrepancy, highlighting a failure to adhere to physician's orders, which could affect the resident's condition.
A facility failed to maintain proper communication and documentation for a resident receiving dialysis, missing several communication forms and post-dialysis assessments. Staff interviews revealed lapses in responsibility and oversight, with recent staffing changes possibly contributing to the issue. The facility's policy required immediate checks of the access site upon return, which were not consistently documented, indicating a lapse in care continuity.
A facility failed to conduct a trauma assessment for a resident with PTSD, Alzheimer's, and anxiety disorder, leading to a deficiency in trauma-informed care. The absence of this assessment meant staff were not fully aware of the resident's history and potential triggers, as revealed in interviews with the Social Worker, DON, and Administrator.
Misappropriation of Discontinued Resident Medication by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when an RN removed discontinued prescription medication belonging to the resident from the facility. The resident was an older individual with senile degeneration of the brain, difficulty walking, and a cognitive communication deficit, and had a BIMS score of 03 indicating severe cognitive impairment. The resident had previously been ordered Meloxicam 7.5 mg, an NSAID for pain and inflammation, with the order ending in late October. Medication Administration Records showed the resident had not received Meloxicam since late October, and there were no current orders for the drug at the time of the incident. During medication cart activities, a medication aide identified two full blister cards (60 tablets total) of Meloxicam for this resident on the cart and brought them to the RN, asking if the medication was still needed. The RN verified in the electronic medical record that the medication had been discontinued. According to the medication aide, she normally would have placed discontinued medications in a locked discontinued box in the medication room after verification, but on this occasion the RN stated she would handle it. The aide reported that the RN placed the two full cards near her computer, and the aide did not see what happened to them afterward. Subsequently, during a police traffic stop unrelated to the facility, law enforcement found two full blister cards containing 60 tablets of Meloxicam 7.5 mg in the RN’s car. A police report identified the pills as belonging to the resident and classified the incident type as criminal. The RN did not deny having the medication and later emailed the facility’s executive director, stating that during a very busy shift she had placed blister-pack medications under papers at the nurse’s station and inadvertently gathered them with her personal belongings when leaving. The executive director, however, stated that the RN had the two full cards in a small laptop case and expressed the belief that the RN could not have taken them accidentally. Facility leadership and the director of clinical operations confirmed that the medication belonged to the resident, that it was discontinued, and that the RN had taken it from the facility, constituting misappropriation of resident property. The facility’s abuse policy stated that each resident has the right to be free from misappropriation of property and that staff must adhere to policies and procedures to prevent such incidents. The storage of medications policy required that all drugs be stored in a safe, secure, and orderly manner and that discontinued drugs be returned to the pharmacy or destroyed. In this case, the RN did not immediately secure the discontinued medication in the locked discontinued box as expected, and instead the resident’s medication was found off-site in the RN’s possession, leading to the determination that the resident was not kept free from misappropriation of property.
Failure to Maintain Accurate and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to care planning and documentation. For one resident with a history of diabetes, schizoaffective disorder, and hypertension, a pressure ulcer present upon re-admission was not included in the care plan until several weeks later, despite nursing documentation and staff interviews confirming the wound's existence and the expectation that such conditions be care planned promptly. The care plan was only updated after a significant delay, even though the wound was reported to the MDS Nurse at the morning meeting following re-admission. Another resident with mobility issues and a history of elopement risk was documented in the care plan as having a wander guard in place, but observations and staff interviews confirmed that the resident did not have a wander guard at the time. The administrator confirmed that no residents currently had wander guards, indicating a discrepancy between the care plan and the resident's actual status. This inconsistency was not identified or corrected by the staff responsible for updating care plans. A third resident, diagnosed with dementia and severe cognitive impairment, was documented in the care plan as residing on a secured memory care unit due to exit-seeking behaviors. However, social services notes and direct observation showed that the resident had been moved to a regular room months earlier, and the care plan was not updated to reflect this change. Interviews with the DON and MDS Nurse revealed confusion and lack of clarity regarding responsibilities for updating care plans, contributing to the failure to maintain accurate and current care plans as required by facility policy.
Failure to Complete Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident received weekly skin assessments as required by facility policy and the resident's care plan. The resident, who had diagnoses including cerebral infarction, atrial fibrillation, COPD, and hypertension, was identified as being at risk for skin breakdown due to factors such as thin, fragile skin, incontinence, and decreased safety during ambulation. Record review showed that while a skin assessment was completed at the beginning of the month, no weekly skin assessments were documented for four consecutive weeks in October. The care plan specifically noted the resident's risk for skin breakdown, and the facility's policy required weekly skin assessments to monitor for issues such as pressure injuries and wounds. Interviews with facility staff confirmed that weekly skin assessments were to be performed by a nurse, not by CNAs. The DON acknowledged that the missing assessments were not completed by a nurse and that the documentation provided for the missing weeks consisted only of shower sheets filled out by CNAs, which are not considered nursing assessments. The facility's policy, last revised in 2022, clearly stated that skin assessments must be documented at least every seven days by nursing staff.
Failure to Maintain Proper Catheter Drainage Bag Positioning
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder, urinary retention, and an indwelling Foley catheter was not provided appropriate catheter care to prevent urinary tract infections. The resident's medical record indicated a recent urinary tract infection, for which antibiotics were prescribed. During an observation, the resident's Foley catheter drainage bag was found lying on the floor under the bed. The resident was unaware that the bag was on the ground. Facility policy required that catheter drainage bags be kept off the floor and secured below the level of the bladder. Interviews with nursing staff, the Director of Clinical Operations, and the Administrator confirmed that all staff were responsible for ensuring catheter drainage bags were kept off the ground. Staff acknowledged that failure to do so could lead to infection and injury. The facility's policy and care plan interventions specifically directed staff to keep the drainage bag off the floor, but this was not followed, resulting in a deficiency related to catheter care and infection prevention.
Inaccurate Wound Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were accurately documented in accordance with accepted professional standards. For one resident, the Treatment Nurse documented in the wound assessment that a pressure ulcer was improving, while the Wound Care Nurse Practitioner (NP) documented on the same day that the wound was worsening. The Treatment Nurse later acknowledged making a mistake in the documentation. The resident had a history of diabetes, schizoaffective disorder, hypertension, and decreased mobility, and was at risk for skin breakdown. The care plan indicated the presence of a pressure ulcer, and the resident was receiving daily wound care and weekly assessments by the Wound Care NP. For another resident, the Treatment Nurse initially documented that a pressure ulcer was worsening, but after an audit, changed the assessment to indicate the wound was improving, despite the Wound Care NP's documentation that the wound was worsening. This resident had diagnoses including lack of coordination, diabetes, obesity, and pressure ulcers, and was moderately cognitively impaired. Interviews with the Wound Care NP and the Director of Nursing (DON) confirmed the expectation that nursing wound assessments should accurately reflect the NP's findings. The facility was unable to provide a policy regarding the accuracy of documentation.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to treat a resident with dignity and respect. The resident, who had diagnoses including Alzheimer's disease, disorganized schizophrenia, and anxiety disorder, was observed to have cognitive deficits and exhibited behaviors such as wandering and exit seeking. During an incident, the resident became agitated after being accidentally bumped by another resident and began yelling and acting as if he might hit the other individual. The LVN intervened by getting between the two residents and, in the process, yelled at the resident, telling him to "sit his ass down." This interaction was witnessed by another staff member and later confirmed by the LVN herself. The facility's policy on resident rights, which was last revised in December 2016, requires that all employees treat residents with kindness, respect, and dignity. The LVN's actions, as described in the report, did not align with this policy. The resident involved was noted to have limited ability to understand or communicate, as indicated by his MDS assessment, and had not exhibited physical or verbal behaviors toward others in the week prior to the incident. The failure to address the resident in a respectful manner constituted a violation of the resident's right to dignity and respect.
Failure to Accurately Document Pressure Ulcer on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident, resulting in the omission of a pressure ulcer that was present upon the resident's re-admission. The resident, who had diagnoses including diabetes, schizoaffective disorder, hypertension, and lack of coordination, was re-admitted to the facility with an existing wound to the buttocks. Nursing progress notes documented the presence of this wound and indicated that it was being treated according to wound care orders. The Treatment Nurse confirmed that the pressure ulcer was present at re-admission and reported it to the MDS Nurse during the morning meeting. Despite this, the MDS assessment completed for the resident did not document the pressure ulcer. The MDS Nurse, who was responsible for completing the assessment, stated that she typically gathered wound information from weekly wound reports, skin assessments, and interdisciplinary team meetings, but acknowledged that she missed documenting the wound in this instance. The facility's policy requires accuracy and timeliness in MDS completion, but this was not followed, resulting in an inaccurate assessment for the resident.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an ongoing and effective pest control program, as evidenced by the presence of cockroaches and water bugs in three of seven resident rooms reviewed. Multiple residents reported seeing roaches and water bugs in their rooms on a regular basis, with one resident specifically noting that his roommate kept uncovered food in the room, which may have contributed to the pest issue. Observations confirmed the presence of live cockroaches in resident rooms and dead bugs in facility hallways. Staff interviews revealed that sightings of pests were common, with some staff members encountering bugs several times a week. Despite the facility's policy requiring staff to log pest sightings in a maintenance book, the maintenance log from April to August showed no entries regarding bugs. Several staff members, including CNAs, were unaware of the requirement to document pest sightings in the logbook and instead reported verbally to the maintenance director or simply disposed of the bugs themselves. The maintenance director was not always present in the facility, and the contracted exterminator, who visited monthly, relied on the logbook to identify problem areas but found it was never utilized. Residents involved had significant medical histories, including chronic heart failure, COPD, diabetes, and a history of infections, making them particularly vulnerable to the health risks associated with pest infestations. Interviews with EMS personnel confirmed that bugs were observed on residents' beds during transfers to the hospital. The facility's failure to implement its pest control policy and ensure effective communication and documentation of pest sightings resulted in ongoing pest issues in resident care areas.
Deficient Food Storage, Kitchen Maintenance, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and kitchen maintenance practices. In Refrigerator #1, a plastic bag containing a light brown round food item was found without a date or label. In the pantry, the wall beneath an air conditioner showed a large gray stain, peeling paint, and a baseboard pulled away from the wall, with a towel pushed against it. There was also a hole in the wall with protruding sheetrock, and a bin containing potatoes with rotten areas and sprouts. Additionally, a cup was found stored inside the sugar bin. Further inspection of the kitchen area revealed that the ceiling under the air conditioning duct was stained, buckled, and secured with brackets, with towels wedged between the vent hood and duct. Five air conditioning vents were observed with gray dust buildup, and one vent had condensation dripping onto the kitchen floor, while another had a black substance present. Interviews with the Maintenance Supervisor and Dietary Manager indicated a lack of clear responsibility for reporting and addressing maintenance issues, cleaning vents, and ensuring proper food labeling and storage. The Dietary Manager acknowledged that all dietary staff were responsible for dating and labeling food, removing rotting food, and not leaving scoops in bulk food items, but these practices were not consistently followed. The Executive Director of Operations (EDO) confirmed that opened foods should be dated and labeled, and that the Dietary Manager was ultimately responsible for ensuring compliance. The EDO also stated that scoops should not be stored in food items, and that any food with signs of aging or decay should be discarded. The EDO noted that the wall and ceiling damage should have been reported and repaired, and that condensation from vents could pose a fall risk. Facility policy review supported the need for proper food labeling, storage, and sanitation, but these standards were not met as evidenced by the survey findings.
Failure to Maintain Freezer at Safe Temperatures Resulting in Thawed Food
Penalty
Summary
The facility failed to maintain Freezer #1 in safe operating condition, resulting in food items being stored at unsafe temperatures and thawing. Review of the kitchen freezer log showed that recorded temperatures for Freezer #1 were within acceptable ranges; however, direct observations on multiple occasions revealed that the outside digital thermometer consistently read "Hi" and the internal temperature was significantly above freezing, reaching as high as 58 degrees Fahrenheit. Food items inside the freezer, including egg rolls, breaded shrimp, and brisket, were found thawed and soft to the touch. Staff interviews confirmed ongoing issues with the freezer, including problems with the door staying open, ice buildup, and malfunctioning fans. The Dietary Manager and Maintenance Supervisor both acknowledged that the freezer had been problematic, with the Maintenance Supervisor stating that the fans had frozen up and were running slowly. There was no documentation of the maintenance performed. The Dietary Manager also indicated that the outside digital thermometer had not been working for some time, and that the internal thermometer was used to monitor temperatures. Despite these measures, food items were not kept frozen as required by facility policy, and the temperature logs did not accurately reflect the actual conditions inside the freezer. Facility policy required that freezers be maintained at 0 degrees Fahrenheit or below, or at a temperature where frozen foods remain frozen. Observations and interviews confirmed that this standard was not met, as food items were allowed to thaw and the freezer was not consistently maintaining safe temperatures. The failure to keep essential kitchen equipment in safe operating condition posed a risk of foodborne illness due to improper food storage.
Failure to Provide Palatable, Attractive, and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents with intact or moderately impaired cognition reported that their meals were consistently cold, lacked flavor, and were repetitive in nature. Specific complaints included vegetables being too salty and watery, food lacking taste, and meals being cold when served in residents' rooms. Several residents also expressed dissatisfaction with the variety and portion sizes, noting that meals often contained insufficient meat and unappealing vegetables, such as repeated servings of mixed vegetables and zucchini. Observations and interviews revealed that these issues were ongoing and had been reported by both residents and staff. Residents described the food as bland, cold, and sometimes burnt or hard. Some residents provided photographic evidence of inadequate portion sizes and poor meal composition, such as sandwiches with minimal filling and hard bread. Staff interviews corroborated these complaints, with reports of frequent negative feedback from residents regarding the taste, temperature, and portion sizes of meals. Staff also indicated that complaints were reported to the dietary department, but improvements were not observed. Review of resident council minutes over several months documented repeated concerns about cold food, lack of variety, and specific requests for preferred items like fried chicken not being met. The facility's dietary manager acknowledged hearing complaints from both staff and residents and noted that the kitchen followed corporate menus. Despite attempts to solicit resident preferences, the issues persisted, as evidenced by ongoing complaints and negative feedback during group interviews and meal observations. The facility's own policy required food to be prepared and served in a manner that preserved flavor, appearance, and proper temperature, but these standards were not consistently met.
Failure to Follow Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow enhanced barrier precautions (EBP) while administering medications and feeding via gastrostomy tube (g-tube) to a resident who required these precautions. The resident, a cognitively intact female with epilepsy, muscle weakness, dysphagia, and a g-tube, was care planned for EBP due to her feeding tube. The care plan specified that staff must don gown and gloves during high-contact care activities, including device care such as g-tube management, and that EBP signage and supplies should be present and accessible in the resident's room. During a medication pass, the RN did not wear a gown while checking g-tube placement, administering medications, and starting tube feeding for the resident. The RN stated it was her first day working with the resident and was unaware of the EBP status, did not see the EBP sign, and did not notice the PPE supplies in the room. However, subsequent interviews confirmed that the EBP sign was posted and PPE supplies were available in the resident's room as required by facility policy. Facility policies and the resident's care plan both required the use of gown and gloves for high-contact care activities involving indwelling medical devices such as a g-tube. The failure to don appropriate PPE during these activities constituted a breach of the infection prevention and control program, as it did not adhere to established protocols designed to prevent the transmission of communicable diseases and infections.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, but does not provide further details about the specific actions or inactions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable level of physical, mental, and psychosocial well-being for residents. The report specifically notes that the staff's competencies were insufficient to ensure that all residents received care tailored to their needs, as required by regulatory standards.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident physically assaulted another with a wheelchair foot pedal. The incident occurred when a male resident with Alzheimer's disease, seizures, and impaired memory, who was known to wander and have behavioral symptoms, entered another resident's room. The second resident, also diagnosed with Alzheimer's disease and a history of aggression, struck the first resident multiple times with a wheelchair leg rest, resulting in lacerations to the scalp, right hand, and right forearm, as well as a worsening subdural hematoma with a midline shift. The assault was witnessed by an LVN, who found the injured resident on the floor and the aggressor holding the weaponized foot pedal. Prior to the assault, the resident who was attacked had already been sent to the emergency room earlier that day for a fall resulting in a laceration and a diagnosed subdural hematoma. After returning to the facility, the resident was assaulted, leading to further injuries and a significant increase in the severity of the brain bleed, as confirmed by emergency department records and CT scans. The resident required transfer to another hospital for a higher level of care due to the increased intracranial pressure. The aggressor resident had a documented history of aggression, was on antipsychotic medication, and was known to be territorial about his space. Both residents were on a secured unit due to wandering and behavioral issues. The incident was reported to the DON and Administrator, and staff interviews confirmed that only one staff member was present in the secured unit at the time. The staff member responded to noises and discovered the assault in progress, but was unable to immediately separate the residents due to being alone. The facility's abuse policy prohibits abuse by anyone, including other residents, but the failure to prevent this altercation resulted in serious harm.
Failure to Prevent Resident-to-Resident Altercation and Unwitnessed Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent incidents and accidents for two of eight residents reviewed. One resident with Alzheimer's disease, impaired memory, and wandering behaviors entered another resident's room and was physically assaulted with a metal wheelchair pedal, resulting in multiple lacerations and a worsening subdural hematoma. The resident who initiated the assault also had Alzheimer's disease, severe cognitive impairment, and a history of aggression, and was known to be territorial about his space. At the time of the incident, only one staff member was present on the secured unit, and the CNA assigned to the unit had left for a break without clear communication, leaving the nurse as the sole supervisor. The nurse was unaware the CNA had left, and the incident was not immediately detected despite audible cues. Another resident with severe cognitive impairment, a history of falls, and dependent on staff for most ADLs experienced an unwitnessed fall from his wheelchair, resulting in a nasal fracture. The resident was found on the floor with bleeding from the nose, and the incident was not observed by staff. At the time, the CNA was on the opposite side of the nurses' station, and the nurse was on the female secured unit, leaving the male secured unit without direct supervision. The resident was identified as high risk for falls, and the care plan included interventions for safe positioning, but these were not sufficient to prevent the fall. Interviews with staff and family members revealed ongoing concerns about inadequate supervision on the secured unit, particularly with increased census and residents exhibiting wandering and aggressive behaviors. Staff reported that one CNA and one nurse were not enough to provide adequate supervision, and there were instances where staff were unaware of each other's whereabouts or when breaks were taken. The facility did not have a specific policy on staffing or supervision for the secured unit, and management acknowledged trends in incidents related to increased census and staffing challenges.
Failure to Maintain Accurate Controlled Substance Records Resulting in Drug Diversion
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and ensure that drug records were in order. Specifically, the facility was unable to account for 55 tablets of Hydrocodone (Norco) prescribed to a male resident with Alzheimer's disease, chronic pain, and type II diabetes. The medication was delivered and signed for, but the corresponding medication card and count sheet could not be located, and the facility was unable to determine the disposition of the controlled substance. During the period in question, the resident was transferred from one unit to another during a shift change. Staff interviews revealed that narcotic counts were not consistently performed during the transfer, and there was no clear documentation of the medication card's receipt or reconciliation at the time of transfer. Several staff members could not recall whether a narcotic sheet was present for the resident, and there was no verified paper trail for the delivery, only an electronic signature. The lack of a consistent and documented process for counting and reconciling controlled substances during shift changes and resident transfers contributed to the inability to account for the missing medication. Observations and interviews further indicated that the facility's procedures for handling and documenting controlled substances were not consistently followed. Staff described varying practices regarding narcotic counts, storage, and documentation, and some were unaware of specific policies such as the clear bag policy. The facility's own policy required detailed recordkeeping and reconciliation of controlled substances, but these procedures were not adhered to, resulting in the unaccounted loss of a controlled medication for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by incidents involving five residents. Resident #1, a male with diagnoses including senile degeneration of the brain and delusional disorders, was involved in an altercation where he struck another resident with a cup. This incident occurred after Resident #2, who has Alzheimer's and PTSD, fidgeted with Resident #1's napkin, leading to a physical confrontation. Despite the intervention of LVN A, the situation escalated, resulting in Resident #1 hitting Resident #2, although no injuries were reported. Another incident involved Resident #3, who has a history of bipolar disorder and was struck by Resident #4. Resident #4, who has Alzheimer's and anxiety disorder, mistakenly entered Resident #3's room and began pulling on his clothes, believing it was his own room. This misunderstanding led to Resident #4 hitting Resident #3 in the cheek. The incident was witnessed by LVN B, who intervened and reported the event to the necessary authorities. Although Resident #3 had a small reddened area on his cheek, no significant injuries were noted. A third incident involved Resident #5, who has Alzheimer's and a cognitive communication deficit. Resident #5 was involved in an altercation with Resident #1, who struck Resident #5 in the upper body region after a verbal disagreement. LVN C witnessed the incident and separated the residents, reporting no injuries. The facility's failure to prevent these resident-to-resident altercations highlights a deficiency in ensuring a safe environment free from abuse for all residents.
Failure to Protect Resident from Abuse by LVN
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by an LVN. The incident occurred when the LVN pushed the resident, resulting in the resident falling to the floor. The resident, who had a history of Alzheimer's, PTSD, and cognitive impairments, was verbally provoked by the LVN before the physical altercation. The resident was known to have poor balance and was at risk for falls, as indicated in his care plan. The incident was witnessed by a CNA who reported that the LVN verbally abused the resident before pushing him. The CNA heard the LVN make derogatory comments towards the resident, which escalated the situation. Despite the resident's verbal agitation, the LVN's response was to physically push the resident, leading to the fall. The CNA reported the incident to the facility's administrator immediately after it occurred. The facility's records indicated that the resident had a history of falls and required supervision with transfers and walking. The care plan noted the resident's potential for aggressive behavior due to confusion and PTSD. However, the LVN's actions did not align with the facility's abuse policy, which mandates that residents be free from abuse by anyone, including staff. The facility's policy requires staff to be trained in abuse prohibition practices, but the LVN's behavior demonstrated a failure to adhere to these standards.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records, leading to a deficiency in resident rights. An LVN used her personal device to video record a resident during an emergent situation without consent and shared the video with an RN. The RN then shared the video with the ADON and BOM. This breach of privacy was compounded by the fact that the resident was not informed of the video recording or its distribution. The resident involved was a male with a history of heart failure, depressive disorder, anxiety disorder, and morbid obesity. He was found unresponsive in his room, and during this vulnerable state, the LVN recorded him. The resident was later informed of the video recording, which caused him emotional distress as he felt violated and taken advantage of during a time when he was not in control of himself. The facility's staff, including the DON and Regional Director of Clinical Services, were aware of the incident but failed to report it to the appropriate state agency in a timely manner. The LVN who recorded the video was suspended and later terminated, but the RN who received the video was not suspended despite failing to report the incident promptly. The facility's inaction and mishandling of the situation contributed to the deficiency in maintaining resident privacy and confidentiality.
Failure to Verify and Document Resident's CPR Preferences
Penalty
Summary
The facility failed to ensure proper documentation and verification of a resident's choice regarding CPR, leading to an Immediate Jeopardy situation. Resident #114, who was admitted with severe medical conditions including acute respiratory failure, heart failure, and severe kidney disease, was incorrectly documented as a Full Code status upon admission. This was despite hospital records indicating a Do Not Resuscitate (DNR) status. The Social Worker (SW) did not verify the resident's code status with the responsible party and inaccurately documented the resident's wishes in the social service assessment. On the day of the incident, the nursing staff performed CPR on Resident #114 after she stopped breathing, based on the incorrect Full Code status. Emergency Medical Services (EMS) were called, and upon their arrival, they found the staff assisting the resident's breathing with a bag valve mask. The EMS attempted intubation, but the resident's responsible party, contacted by phone, stated they did not want any invasive procedures, including CPR or intubation, and wished for the resident to pass naturally. This discrepancy between the documented code status and the family's wishes highlighted the facility's failure to have a system in place to ensure accurate documentation and verification of advance directives. Additionally, the facility did not maintain a system to track and ensure that all nursing staff had current CPR certifications. The Director of Nursing (DON) admitted that CPR certifications were not tracked after hire, and the facility could not provide current CPR cards for most of the nursing staff. This lack of oversight and documentation could potentially lead to residents receiving unwanted life-saving measures, as was the case with Resident #114.
Failure to Obtain Informed Consent for Psychotropic 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 psychotropic medications. For Resident #60, the facility did not obtain a signed psychotropic consent form for Trazodone, an antidepressant medication. Despite the resident's severe cognitive impairment, indicated by a BIMS score of 3, and the medication being administered as ordered, there was no documented consent. The resident's wife stated she had given verbal consent over the phone, but the responsible nurse admitted to forgetting to complete the necessary documentation. For Residents #30 and #56, the facility did not fill out the section on the consent forms that detailed the need for and benefits of the proposed treatment with antipsychotic or neuroleptic medications. Resident #30, with a BIMS score of 7 indicating severely impaired cognition, was taking Risperidone and Gabapentin, but the consent forms lacked critical information. Similarly, Resident #56, who had no cognitive impairment, was taking Vimpat for epilepsy, but the consent form was incomplete. The Assistant Director of Nursing (ADON) admitted to filling out the forms based on previous practices without proper training. Interviews with various staff members, including the Director of Nursing (DON), ADON, and the Administrator, revealed a lack of oversight and responsibility in ensuring that consent forms were completed accurately and thoroughly. The facility's policy on psychotropic medication review did not address the need for consent forms, contributing to the oversight. This failure to obtain informed consent could lead to residents receiving medications without understanding the associated risks and benefits.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for four residents. Resident #13's care plan was not updated to reflect his election of hospice services, despite having an order to admit to hospice dated 5/17/2024. The care plan was only updated after state surveyor intervention, indicating a lapse in timely documentation and coordination of care. Resident #39's care plan was not revised to reflect his relocation from the secured unit, despite observations confirming his presence in a different area of the facility. The care plan still indicated he resided on the memory care unit due to being an elopement risk, which was not accurate at the time of the survey. Similarly, Resident #44's care plan failed to include his continuous use of oxygen therapy, despite multiple observations of him receiving oxygen at a rate of 3.5 liters per minute. Resident #59's care plan was not updated to reflect the discontinuation of antibiotic therapy and the removal of his PICC line, which had been in place since March 2024. Observations confirmed the absence of a PICC line or IV therapy equipment in his room. Interviews with facility staff, including the DON, ADON, and MDS Coordinator, revealed that care plans were expected to be updated during morning meetings and reviewed regularly, yet these deficiencies indicate a failure in the process, potentially leading to residents receiving inaccurate care.
High Medication Error Rate in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 73.08% based on 19 errors out of 26 opportunities. This involved three residents who were reviewed for medication administration. The errors included late administration of medications for two residents and incorrect administration for another resident, which could potentially affect the therapeutic benefits of the medications. Resident #14, a male with multiple health conditions including multiple sclerosis and type 2 diabetes, did not receive his medications within the scheduled time frame. The medications were administered late due to staffing issues, as the nurse had to assist with other duties. This delay in medication administration was acknowledged by the nurse, who stated that it could potentially lead to adverse effects. Resident #24, a male with type 2 diabetes, received his insulin later than scheduled. The nurse delayed the administration based on her judgment of the resident's blood sugar levels and the timing of meal service. Resident #56, a female with paranoid schizophrenia, was given the wrong medication and had an ointment applied incorrectly to both extremities instead of one. The nurse involved admitted to not verifying the medication properly and acknowledged the potential risks of such errors.
Deficiency in Timely Meal Service Due to Insufficient Support Personnel
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, resulting in meals being served late on multiple occasions. Observations and interviews revealed that lunch meals on specific dates were not served on time, with delays ranging from 17 minutes to over an hour. The Dietary Manager and staff acknowledged the issue, attributing it to staff turnover and lack of available help in the kitchen. The Dietary Manager admitted to monitoring the situation through random spot checks and acknowledged reports from staff and residents about the delays. Interviews with the Dietician Consultant and the Administrator highlighted expectations for meals to be served on time, emphasizing the importance of timely meal service for residents' health and nutrition. The Administrator noted that the issue was partly due to inexperience in management and mismanagement of time, with staff not arriving early enough to prepare meals. Despite requests, the facility did not provide a policy regarding meals served on time before the exit interview.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Key deficiencies included undated food items such as English muffins, coleslaw, hashbrowns, mixed vegetables, and sweet potato fries, which were not labeled with the date they were removed from their original packaging. Additionally, the juice machine spigot was found with a red gooey substance, and muffin pans were coated with encrusted black grease. The steam pans were improperly stacked with water pooled between them, and both the microwave and stove were not cleaned, showing food debris and buildup. Interviews with various staff members, including the Director of Environmental Services, Dietician Consultant, Dietary Aide, and Dietary Manager, revealed a lack of adherence to cleaning protocols and food safety practices. The Director of Environmental Services admitted to entering the kitchen without a hair restraint, acknowledging the importance of preventing food contamination. The Dietician Consultant and Dietary Aide both emphasized the need for proper dating of food items, cleaning of equipment, and adherence to cleaning schedules. The Dietary Manager admitted to being unaware of the expiration dates on test strips and acknowledged the lack of task assignments for cleaning duties. The Administrator confirmed expectations for food safety practices, including dating food items, drying pans before stacking, and cleaning equipment after each use. However, the facility's policies on food storage and service uniforms were not fully implemented, as evidenced by the observations and interviews. The absence of a general kitchen sanitation policy further highlighted the facility's failure to maintain a safe and sanitary food service environment, potentially putting residents at risk for foodborne illness and contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #11's urine specimen was not collected properly, leading to potential contamination and the presence of multiple drug-resistant organisms. Despite these findings, Resident #11 was not placed on isolation precautions, and the staff failed to re-collect a clean urine specimen. The Assistant Director of Nursing (ADON) admitted to not providing proper education on obtaining a clean-catch urine specimen and was unaware of the antibiotic-resistant organisms in Resident #11's urine. Resident #44, who had an indwelling catheter, did not receive proper incontinent and catheter care. The hospice aide failed to change gloves between dirty and clean tasks and did not perform hand hygiene during the care process. Additionally, the hospice aide did not clean the resident's penis and catheter tubing correctly. Enhanced barrier precautions were not followed, despite being posted in the resident's room. The Director of Nursing (DON) and ADON acknowledged the importance of proper catheter care and the use of PPE to prevent infections but failed to ensure these practices were followed. In the men's secure unit dining room, a medication aide (MA) was observed eating a donut while serving lunch trays to residents, which posed a risk of cross-contamination. The DON and ADON both stated that eating while serving residents was not acceptable due to infection control concerns. The failure to adhere to proper infection control practices in these instances placed residents and staff at risk for cross-contamination and the spread of infections.
Failure in Infection Control and Antibiotic Stewardship
Penalty
Summary
The facility failed to establish an infection prevention and control program that includes an antibiotic use protocol and a system to monitor antibiotic use, as evidenced by the case of a resident who was not assessed using established criteria to determine if her urinary tract infection (UTI) met the criteria for antibiotic use. The resident, a female with schizophrenia, multiple sclerosis, and parkinsonism, was admitted to the facility and had a history of bladder incontinence, placing her at risk for infection. Despite this, the facility did not ensure proper assessment and documentation regarding her UTI and antibiotic use. The resident's urine culture and sensitivity results showed multiple bacterial organisms, some of which indicated potential contamination. The Assistant Director of Nursing (ADON), who was responsible for infection control, admitted to not providing education on obtaining a clean-catch urine specimen and was unsure if the resident cleaned herself before providing the sample. The ADON also acknowledged that the culture results should have prompted contact isolation precautions and a re-collection of the specimen, which did not occur. Furthermore, the ADON noted a lack of education among nurses regarding the McGeer's criteria for infection, which contributed to the oversight. Interviews with the Director of Nursing (DON) and the Assistant Administrator revealed that the ADON was responsible for reviewing urinalysis results and ensuring proper follow-up with nursing staff and physicians. However, the DON noted that the urine specimen was likely contaminated, and the physician should have been notified if the resident did not meet the criteria for antibiotic use. The facility's failure to implement proper infection control measures and antibiotic stewardship policies led to the deficiency, as evidenced by the lack of documentation and appropriate response to the resident's condition.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the main building, including the dining room, hallway, and several resident rooms. The pest control log indicated that the pest control company serviced the facility on multiple occasions, but the log did not specify the areas serviced. A service notification from the pest control company noted that no issues were reported by the facility, and no additional measures were implemented to address the fly problem. Observations and interviews revealed multiple instances of flies buzzing around and landing on residents and their food. Residents expressed annoyance, and some were unable to communicate effectively due to confusion. Staff interviews indicated that the facility's doors were often propped open, allowing flies to enter, especially during meal times. Staff members, including CNAs and RNs, acknowledged the issue and the importance of maintaining a sanitary environment, but no effective measures were taken to prevent the flies from entering the facility. The Director of Plant Operations and the Assistant Administrator were aware of the fly problem but did not take additional actions beyond the regular pest control visits. The Director of Plant Operations mentioned that a door fan was out of order, contributing to the issue, and the Assistant Administrator stated that the pest control company could have been called for additional visits but was not. The facility's pest control policy emphasized the importance of keeping the building free of insects and rodents, but the policy was not effectively implemented.
Failure to Explain Arbitration Agreement to Resident's Representative
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a form and manner, including a language that the resident or their representative understood. This deficiency was identified for one resident, who had severe cognitive impairment due to Alzheimer's disease, schizoaffective disorder, and bipolar disorder. The resident's responsible party, who was also the emergency contact, signed the arbitration agreement electronically as part of the admission packet without being aware of it. The responsible party stated that the facility did not go over the admission packet with her, and she signed everything quickly without understanding that she was entering into a binding arbitration agreement. Interviews with facility staff revealed that the responsibility for ensuring the admission packets were completed had been passed among several staff members, and there was no consistent process for explaining the arbitration agreement. The Business Office Manager (BOM) stated that when admission packets were completed electronically, the pages were only explained if families had questions. The BOM acknowledged the importance of ensuring that residents or responsible parties were aware of what they were signing. The Assistant Administrator expected staff to explain the arbitration agreement, but there was no policy related to arbitration in place at the facility.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate hospice care for a resident, leading to a deficiency in the quality of end-of-life care. The resident, an elderly male with severe cognitive impairment, was admitted to hospice services with a terminal diagnosis of malnutrition. Despite the resident's admission to hospice, the facility did not collaborate effectively with the hospice provider, resulting in a lack of documentation and communication regarding the resident's care needs. Interviews with facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that there was no coordination of care between the facility and the hospice provider. The DON was unable to locate the hospice binder or contact the hospice agency, and there was no clear understanding of the responsibilities of each party involved in the resident's care. This lack of coordination and communication posed a risk to the continuity of care for the resident. The facility's hospice program policy outlined the responsibilities for coordinating care with hospice providers, including obtaining necessary documentation and ensuring communication with hospice representatives. However, these procedures were not followed, leading to a gap in services and potential emotional distress for the resident and their family. The deficiency was identified during a survey, highlighting the facility's failure to ensure the quality of care for residents receiving hospice services.
Failure to Follow Breakfast Menu
Penalty
Summary
The facility failed to adhere to the scheduled breakfast menu for residents on 05/22/2024, which included oatmeal, sausage patty, and waffle. Observations revealed that there were no sausages or waffles available on the steam table prepared for breakfast. The absence of these items was not communicated to the residents, and no substitutions were offered. This oversight was confirmed through interviews with the Dietician Consultant, who emphasized the importance of following the menu to ensure residents receive the correct nutritional value. Further interviews with the Dietary Manager and the Administrator revealed a lack of communication and monitoring regarding menu adherence. The Dietary Manager acknowledged that there was a miscalculation in the sausage inventory due to overcooking by the weekend cook, and a mix-up in the breakfast schedule. The Administrator admitted that while there was a system in place to address unavailable items, it failed on this occasion, and she recognized the need for revision. The facility's policy on food preparation, which mandates adherence to standardized recipes and planned menus, was not followed, leading to this deficiency.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents reviewed for pharmacy services. Resident #14, a male with multiple health conditions including multiple sclerosis, type 2 diabetes, and hypertension, did not receive his medications within the scheduled time frame. The medications, which included pain relievers, anticonvulsants, and antihypertensives, were administered late due to staffing shortages, as explained by RN B. This delay in medication administration was observed and confirmed through interviews and record reviews. Similarly, Resident #24, a male with type 2 diabetes, also experienced a delay in receiving his prescribed insulin. The insulin was administered later than scheduled because RN B used her nursing judgment to delay the administration due to the resident's blood sugar level and the timing of meal service. This decision was made to prevent potential hypoglycemia, but it was not in accordance with the scheduled administration time. The Director of Nursing (DON) and the Administrator acknowledged the importance of timely medication administration and the adherence to physician orders. The facility's policy requires medications to be administered within one hour before or after the scheduled time, and the failure to do so was noted as a significant deficiency. The DON stated that monitoring and verbal in-service training had been conducted to address this issue, but the deficiency persisted, potentially leading to adverse reactions.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service in the women's secure unit dining room. During a dining observation, an LVN referred to residents needing assistance with feeding as 'feeders' while distributing meal trays. This terminology was acknowledged by the LVN as inappropriate and potentially embarrassing for the residents, as it did not promote a dignified existence or enhance their quality of life. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed that the use of the term 'feeder' was considered a dignity issue. They emphasized the importance of using respectful language, such as 'assist to dine,' to avoid emotional harm and maintain a homelike environment. The facility's policy on Quality of Life - Dignity, revised in August 2009, mandates that staff speak respectfully to residents, addressing them by their name of choice and not by their care needs.
Failure to Timely Provide Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records to his attorney within the required two working days after a request was made. The resident, a male with Alzheimer's Disease, diabetes, and a history of stroke, had a significant cognitive impairment with a BIMS score of 7. Despite a formal request for records being made on November 27, 2023, and a signed release form being provided, the records were not delivered until May 2024, following multiple requests and delays. Interviews with facility staff revealed a lack of clarity and communication regarding the process for handling medical records requests. The Director of Nursing (DON) was unaware of the approval process at the corporate level, and the Business Office Manager (BOM) found the initial request in December 2023 but was unsure why it was not processed. The BOM sent the request to corporate twice, but the records were only sent to the attorney in May 2024. The Assistant Director of Nursing (ADON) and Assistant Administrator also expressed uncertainty about the release process, indicating systemic issues in the facility's handling of medical records requests.
Failure to Ensure Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the rights of a resident to formulate an advance directive, specifically regarding the accuracy and consistency of the resident's code status. The resident, a male with severe cognitive impairment and various neurocognitive and psychotic disorders, had conflicting documentation regarding his code status. The care plan indicated a full code status, while the physician's order summary and the out-of-hospital do-not-resuscitate (OOH-DNR) form indicated a DNR status. However, the OOH-DNR form was missing the signature of the responsible party, rendering it incomplete and potentially invalid. Interviews with facility staff, including the Social Worker, Business Office Manager, Director of Nursing (DON), and Administrator, revealed a lack of proper oversight and verification of the DNR documentation. The Social Worker and Business Office Manager acknowledged their roles in ensuring the accuracy of DNR forms, with the Business Office Manager noting the legal importance of a correctly filled DNR. The DON and Administrator both emphasized the necessity of complete and accurate DNR forms to honor the resident's wishes, with the Administrator indicating plans to monitor the process during morning meetings. Despite these acknowledgments, the facility's policy for DNR was not provided upon request.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment in the men's secure unit dining room by serving meals on trays during lunch mealtimes. Observations on two separate days revealed that LVN U left plates on the lunch trays, which was contrary to the facility's policy of creating a homelike environment. During interviews, LVN U admitted to leaving the plates on the trays for convenience, without understanding the impact on residents' dignity and quality of life. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both expressed expectations that plates should be removed from trays to avoid institutionalization and maintain residents' dignity. However, the Administrator expressed concerns about the residents' cognitive abilities and the potential for messes if plates were removed from trays. The facility's policy, revised in 2017, emphasizes the importance of providing a safe, clean, comfortable, and homelike environment, which was not adhered to in this instance.
Failure to Apply Contracture Prevention Device for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease of range of motion (ROM) for a resident with contractures. Resident #215, a male with end-stage renal disease and hemiplegia affecting his left side, was observed without a contracture prevention device in place for his left hand, wrist, and elbow. Despite the comprehensive care plan indicating the need for a splint, there were no orders addressing the contractures, and the resident reported not having the splint applied since returning from the hospital. Interviews with staff revealed a lack of clarity and responsibility regarding the application of the splint. The Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON) indicated that the splint should have been applied daily, but it was not. The Director of Rehabilitation (DOR) confirmed that the resident was not receiving therapy services and that nursing staff were responsible for applying the splint when therapy was not involved. However, there was no active order for the splint, and the nursing staff had not been applying it. The Director of Nursing (DON) and other staff members acknowledged the importance of the splint in maintaining the resident's mobility and preventing further decline. However, the facility lacked a restorative program and a policy on contracture management, leading to a gap in care. The Assistant Administrator expected an order reconciliation upon the resident's return from the hospital, but this was not completed, resulting in the deficiency.
Inadequate Catheter Care and Securing Practices
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for two residents with indwelling urinary catheters. Resident #13, a male with severe cognitive impairment and obstructive uropathy, had a Foley catheter that was not properly secured to his leg. The comprehensive care plan for Resident #13 did not address the need for a securing device for the catheter, which could lead to trauma and increased risk of infection. During an observation, a registered nurse confirmed that the catheter was not secured, acknowledging the potential for trauma. Resident #44, also a male with severe cognitive impairment and obstructive uropathy, was similarly affected by the lack of a securing device for his Foley catheter. Despite the care plan indicating the need for a Velcro strap to secure the catheter, observations revealed that the catheter was not secured, posing a risk of trauma. Additionally, Resident #44 had an abnormal urinalysis indicating a urinary tract infection, for which he was prescribed antibiotics. The hospice aide responsible for his care failed to perform proper catheter care, including not cleaning the catheter tubing and not changing gloves between dirty and clean tasks, which could contribute to infection risk. Interviews with staff, including the Director of Nursing and Assistant Director of Nursing, highlighted expectations for proper catheter care and securing devices to prevent trauma and infections. However, the facility's failure to ensure these practices were followed, particularly with contracted staff, resulted in deficiencies in care for both residents. The lack of proper training and oversight contributed to the inadequate care provided, increasing the risk of urinary tract infections and other complications.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, a male with Alzheimer's Disease and obstructive and reflux uropathy, was prescribed oxygen at 2-3 liters per minute via nasal cannula. However, observations revealed that the resident was receiving oxygen at a rate of 3.5 liters per minute, which exceeded the physician's orders. This discrepancy was noted during multiple observations, and the nurse responsible was initially unaware of the correct order. Interviews with the LVN, DON, ADON, and Assistant Administrator confirmed that the oxygen was not set according to the physician's orders, which could potentially affect the resident's condition. The staff acknowledged their responsibility to ensure that oxygen therapy was administered as prescribed. The facility's policy on oxygen therapy emphasized the importance of verifying orders, including the method of delivery and flow rate, to ensure safe administration.
Failure in Dialysis Care Communication and Documentation
Penalty
Summary
The facility failed to provide consistent dialysis care in accordance with professional standards for a resident with end-stage renal disease. The resident, who had moderately impaired cognition, received hemodialysis three times a week and had an indwelling shunt in his right forearm. The facility did not maintain ongoing communication with the dialysis center, as evidenced by missing dialysis communication forms on several dates and the absence of post-dialysis assessments on two occasions. This lack of documentation and communication could potentially place residents at risk for complications and inadequate care. Interviews with facility staff, including the ADON, DON, RN, and Assistant Administrator, revealed that the responsibility for completing and monitoring dialysis communication forms was not consistently upheld. The charge nurse was responsible for ensuring the forms were filled out, but the DON admitted that recent staffing changes might have contributed to the oversight. Despite weekly checks of the dialysis binder, the missing forms were not identified. The facility's policy required immediate checks of the access site upon the resident's return from dialysis, but this was not consistently documented, indicating a lapse in the continuity of care and communication with the dialysis center.
Failure to Conduct Trauma-Informed Care Assessment
Penalty
Summary
The facility failed to ensure that a resident who is a trauma survivor received culturally competent, trauma-informed care. Specifically, the facility did not conduct a trauma screening for a resident with a history of trauma, including diagnoses of Alzheimer's disease, post-traumatic stress disorder (PTSD), and anxiety disorder. The resident's comprehensive care plan included interventions for PTSD triggers, but the absence of a trauma assessment meant that staff were not fully informed of the resident's history and potential triggers. Interviews with facility staff, including the Social Worker, Director of Nursing (DON), and Administrator, revealed that the trauma assessment was not completed upon the resident's admission. The Social Worker acknowledged the oversight, stating that she was not employed at the facility at the time of the resident's admission and was unaware that the assessment had not been conducted. Both the DON and Administrator emphasized the importance of the trauma assessment in understanding the resident's needs and preventing potential harm, but the responsibility for completing the assessment was not fulfilled, leading to a deficiency in care.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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