Fox Hollow Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsville, Texas.
- Location
- 310 America Dr, Brownsville, Texas 78526
- CMS Provider Number
- 676398
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Fox Hollow Post Acute during CMS and state inspections, most recent first.
A disposable razor was found left on top of a linen cart in the 600 hallway, rather than being secured or disposed of in a sharps container. A CNA reported she had not noticed the razor and believed it was left by the previous shift, and both the CNA and an LVN acknowledged that the razor should have been placed in a sharps container to prevent resident injury. The DON stated that razors are supposed to be kept locked in the supply room for CNAs, consistent with facility policy that emphasizes maintaining an environment free from accident hazards and prioritizing resident safety and supervision.
A CNA provided direct care to residents for several months with an expired certification due to lapses in the facility's verification and reminder processes. Leadership and HR were unaware of the expired status until a review was conducted, and the CNA continued to work without a valid certification, contrary to facility policy.
A resident who was fully dependent for transfers suffered a fractured toe when her foot struck the mast of a mechanical lift during a transfer by two CNAs who failed to protect her feet and did not immediately report the incident, despite the resident expressing pain. The facility lacked a policy on mechanical lift use and did not ensure staff consistently reported changes in resident condition, contributing to the injury.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy when the resident was transferred to a hospital. The resident, with multiple health conditions, was readmitted to the facility without documentation of a bed-hold notice. Interviews revealed confusion over responsibility for issuing these notices, contrary to the facility's policy requiring notice both in advance and at the time of transfer.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. A resident with severe cognitive impairment and respiratory conditions received oxygen at an incorrect rate, while another resident with heart failure and respiratory failure also received oxygen at an incorrect rate. Additionally, a resident with morbid obesity and muscle weakness was receiving oxygen therapy without appropriate orders, highlighting a significant oversight in the facility's respiratory care management.
A facility failed to maintain proper infection control practices, as evidenced by an LVN entering a resident's room on contact precautions without PPE and an AD handling food without changing gloves after touching a resident's wheelchair. Despite regular in-service training, these incidents highlight lapses in adherence to infection control protocols.
A resident with multiple health conditions was admitted to an LTC facility without physician orders for necessary oxygen therapy. Despite receiving oxygen since admission, the facility's records did not initially reflect this need, and staff confirmed the absence of timely orders. The facility's policies require physician orders for oxygen, which were not obtained, placing the resident at risk.
The facility failed to develop comprehensive care plans for two residents, one requiring oxygen therapy and another with Alzheimer's disease. The care plans did not reflect the residents' needs due to missing documentation and communication issues among staff, leading to inadequate care planning.
The facility failed to store and prepare food according to professional standards, as raw beef was improperly stored next to lettuce in the refrigerator, and raw meat was thawed in a 3-compartment sink. Staff interviews confirmed that these practices did not comply with the facility's policies and the FDA Food Code, posing a risk of cross-contamination.
A facility failed to accurately document a resident's falls in the Discharge MDS assessment. The resident, with severe cognitive impairment and multiple health issues, experienced falls that were noted in the care plan but not reflected in the MDS. Interviews with staff confirmed the oversight, which could lead to improper care due to inaccurate records.
A resident reported her wallet missing, but the facility failed to complete the grievance form and follow up on the issue. The resident was not informed about the investigation, except that a police report was made. The Administrator admitted to not filling out the form, and the DON explained that grievances were documented in binders and discussed in meetings, but the responsibility for completion varied.
A resident with pneumonia and severely impaired cognition was prescribed continuous oxygen therapy, but the facility failed to include this in the care plan. Despite the resident using oxygen, it was not documented in the care plan or marked in the MDS assessment. Interviews with staff revealed a lack of coordination in updating the care plan, leading to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions was found with a urinary catheter bag touching the floor, contrary to facility policy. Staff interviews revealed inconsistencies in catheter care practices, posing a risk for cross-contamination and urinary tract infections.
A resident was discharged from a facility without the required 30-day notice due to financial issues and non-compliance with Medicaid application processes. The resident's family member was informed of the discharge only a few days prior, and the facility staff believed the discharge was mutually agreed upon. However, the facility's policy did not explicitly require a 30-day notice, leading to the deficiency.
The facility failed to re-admit a resident after hospitalization, despite a pending appeal against a discharge notice. The resident had a history of aggressive behavior and medication refusal, and the facility cited these issues as reasons for not allowing his return, violating their written policy.
Unsecured Disposable Razor Left on Hallway Linen Cart
Penalty
Summary
Surveyors identified a deficiency when a disposable razor was found left on top of the 600 hallway linen cart, rather than being secured or disposed of properly. During an evening observation, the surveyor saw the razor on the cart, and a CNA on duty acknowledged she had not noticed it and stated it had been left there by the previous shift. The CNA further stated the razor should have been disposed of in a sharps container because any resident could grab it and get hurt. An LVN also confirmed that the razor should not have been on top of the linen cart and should have been disposed of in a sharps container. The DON later stated that razors are supposed to be kept under lock and key in the supply room for CNAs and acknowledged that any resident could grab the razor and cause harm. Facility policy on Safety and Supervision of Residents, revised July 2017, states that the facility strives to make the environment as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. This deficiency reflects the facility’s failure to ensure the resident environment remained as free of accident hazards as possible by allowing a disposable razor to be left unsecured on a linen cart in a resident hallway, contrary to staff statements and written policy regarding safe handling and storage of razors.
Failure to Ensure Nurse Aide Maintained Active Certification
Penalty
Summary
The facility failed to ensure that a nurse aide (CNA A) maintained a current and active certification while employed and providing direct care to residents. Record reviews showed that CNA A's nurse aide certification had expired, and she continued to work for approximately four months, accumulating around 700 hours of resident care with an expired certification. The Texas Nurse Aide Public Registry confirmed the expired status, which rendered CNA A not employable as a nurse aide in a licensed nursing facility in Texas during that period. Interviews with facility leadership, including the Administrator, DON, and HR, revealed a lack of consistent and timely verification of staff certification statuses. The Administrator and DON were unaware of the expired certification until it was identified during a review, and both stated that staff were responsible for renewing their certifications, with HR acting as a backup. HR confirmed that certifications were checked upon hire and then yearly, but no reminders or regular reports were sent to staff or leadership regarding upcoming expirations. The facility's policy required staff to present recertifications prior to expiration and maintain current certification, but this was not followed in CNA A's case. CNA A stated she was unaware her certification had expired and had relied on previous reminders from the facility, but acknowledged it was ultimately her responsibility to ensure her certification was active. She continued to provide care to residents during the period her certification was expired. The deficiency was identified when personnel files were reviewed, and it was confirmed that CNA A had been working without a valid certification, contrary to facility policy and regulatory requirements.
Failure to Protect Resident During Mechanical Lift Transfer Results in Injury
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent for transfers due to a history of cerebral infarction and spinal stenosis, was being transferred from bed to wheelchair using a mechanical lift by two CNAs. During the transfer, the resident's left foot struck the mast of the mechanical lift, resulting in an acute fracture of the third digit proximal phalanx. The CNAs failed to protect the resident's feet during the transfer, and did not immediately report the incident to the charge nurse, despite the resident expressing pain and showing signs of injury. The resident later reported severe pain to an Occupational Therapy Assistant (OTA) during therapy, who observed bruising and escalated the concern to the Director of Rehabilitation (DOR) and then to the LVN. The LVN assessed the resident, noted discoloration, and notified the nurse practitioner, who ordered x-rays confirming the fracture. Interviews revealed that both CNAs involved in the transfer did not consider the incident significant enough to report at the time, even though the resident had expressed discomfort and grunted when her foot was injured. Further review found that the facility did not have a policy on mechanical lift use, and staff had not consistently reported changes in resident condition as required. The lack of a mechanical lift policy and failure to ensure adequate supervision and protection during transfers contributed to the accident and subsequent injury. These failures placed residents at risk of injury due to inadequate hazard prevention and supervision.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notice to a resident and their representative regarding the duration of the bed-hold policy when the resident was transferred to a hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff and the resident's representative. The resident, an elderly female with multiple diagnoses including muscle weakness, encephalopathy, type 2 diabetes, Alzheimer's disease, and seizures, was admitted to the hospital and later readmitted to the facility. However, there was no documentation of a bed-hold notice being provided at the time of the hospital transfer. Interviews with the Director of Nursing (DON) and the facility Administrator revealed a lack of clarity regarding the responsibility for issuing bed-hold notices. The DON indicated that nursing was not responsible for providing these notices, while the Administrator stated that the bed-hold form was included in the admission agreement and managed by the Business Office Manager, who was unavailable at the time. The facility's policy requires that residents and their representatives receive written notice of the bed-hold policy both in advance of any transfer and at the time of transfer, but this procedure was not followed in this case.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. Resident #260, a 75-year-old female with severe cognitive impairment and multiple respiratory conditions, was observed receiving oxygen at 2.5 LPM instead of the prescribed 2 LPM. The nurse responsible for Resident #260 claimed the concentrator's reading was accurate when checked at a slanted angle, but this was inconsistent with the prescribed rate. Despite the discrepancy, Resident #260 did not exhibit symptoms of respiratory distress at the time of observation. Similarly, Resident #261, an 82-year-old female with acute and chronic congestive heart failure and respiratory failure, was observed receiving oxygen at 1.5 LPM instead of the prescribed 2 LPM. The nurse assigned to Resident #261 also claimed the concentrator's reading was accurate when checked at a slanted angle. Although Resident #261 did not show signs of respiratory distress during the observation, the incorrect oxygen rate could potentially lead to complications. Resident #79, a 73-year-old female with morbid obesity and muscle weakness, was receiving oxygen therapy without appropriate orders. The resident had been on oxygen since admission, but there were no documented orders for continuous oxygen therapy until a PRN order was received later. Staff interviews revealed that the resident had been receiving oxygen intermittently, and there was confusion about the necessity of a physician's order for oxygen administration. The lack of proper documentation and verification of orders for Resident #79's oxygen therapy highlighted a significant oversight in the facility's respiratory care management.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by two specific incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) entered the room of a resident on contact precautions without donning the required personal protective equipment (PPE), specifically a gown and gloves. This was despite clear signage indicating the need for such precautions. The LVN believed that PPE was only necessary when providing direct care, such as wound care, rather than upon entering the room. Interviews with other staff members, including Certified Nursing Assistants (CNAs) and the Director of Nursing (DON), revealed a general understanding of the need for PPE in such situations, although the LVN's actions suggested a lapse in adherence to these protocols. In the second incident, an Activity Director (AD) was observed handling food while wearing gloves, then touching a resident's wheelchair without changing gloves before resuming food handling. The AD acknowledged the need to change gloves and perform hand hygiene after touching potentially contaminated surfaces, yet failed to do so in practice. This incident highlights a gap between knowledge and execution of infection control practices, as confirmed by interviews with the AD and other staff members who reiterated the importance of hand hygiene and glove changes between tasks. The facility's policies on hand hygiene and transmission-based precautions were reviewed, indicating that staff are regularly in-serviced on these protocols. However, the observed deficiencies suggest that despite frequent training, there are inconsistencies in the application of infection control measures. The facility's leadership, including the DON and Administrator, acknowledged the importance of these protocols and the need for staff to adhere to them to prevent the spread of infections within the facility.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #79, had physician orders for immediate care upon admission, specifically for oxygen therapy. Resident #79, a 73-year-old female with diagnoses including morbid obesity, muscle wasting, muscle weakness, and hypertension, was admitted to the facility and required continuous oxygen therapy. However, the care plan completed shortly after admission did not reflect the need for oxygen therapy, and there were no initial physician orders for oxygen documented in the resident's medical records. Despite the absence of documented orders, Resident #79 was observed receiving oxygen therapy, and staff interviews confirmed that the resident had been on oxygen since admission. The facility's staff, including a CNA and LVN, acknowledged that the resident had been using oxygen intermittently, and the LVN mentioned that the resident was initially taken off oxygen upon admission due to stable oxygen saturation levels. However, a new order for PRN oxygen was only received on a later date, after the resident exhibited symptoms of shortness of breath and edema. The facility's policies on oxygen administration and medication orders require a physician's order for oxygen therapy, which was not obtained in a timely manner for Resident #79. Interviews with the ADON and DON revealed that there were no standing orders for PRN oxygen, and the facility's protocol was not followed, as there were no progress notes indicating respiratory distress prior to the receipt of the PRN oxygen order. This oversight placed the resident at risk of not receiving appropriate physician-ordered care.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in their care. Resident #79, a 73-year-old female with multiple diagnoses including morbid obesity and hypertension, was not provided with a care plan that included her need for oxygen therapy. Despite being on oxygen since her admission, this requirement was not reflected in her care plan or MDS assessment. Interviews with staff revealed a lack of communication and documentation regarding the resident's oxygen therapy, which was not included in the care plan due to missing orders in the system. Resident #100, diagnosed with Alzheimer's disease, also did not have a comprehensive care plan addressing her condition or the medication memantine prescribed for her dementia. The care plan was not completed within the required timeframe, and staff interviews indicated a breakdown in the process of updating and communicating care plans. The MDS Nurse was unaware of the need for specific care due to the absence of orders in the chart, leading to an incomplete care plan. The facility's policy requires the development of a comprehensive, person-centered care plan within 21 days of admission, but this was not adhered to for the residents in question. The lack of proper care planning could result in inadequate care and services for the residents, as staff rely on these plans to understand and meet the residents' needs. The deficiency highlights issues in the facility's documentation and communication processes, which are crucial for ensuring residents receive appropriate care.
Improper Food Storage and Preparation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage and preparation of food. During an observation of the kitchen, it was noted that raw beef was improperly stored next to lettuce on a shelf inside the walk-in refrigerator. Additionally, raw meat was observed being thawed in a 3-compartment sink, which is not in line with safe food handling practices. Interviews with staff confirmed that the raw meat should have been stored on the bottom shelf to prevent cross-contamination, as per the facility's policy and the U.S. Food and Drug Administration Food Code. The facility's policy on food receiving and storage, revised in November 2022, clearly states that uncooked and raw animal products should be stored separately and below fruits and vegetables to prevent contamination from meat juices. The deficiency was further highlighted by the facility's policy on food preparation and service, which mandates compliance with safe food handling practices. The failure to follow these guidelines was acknowledged by the staff and the administrator, indicating a lapse in adherence to established protocols designed to protect residents from foodborne illnesses.
Failure to Accurately Document Resident Falls in Discharge MDS
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the status of a resident, specifically regarding falls. The resident, an 83-year-old female with Alzheimer's, dementia, muscle wasting, and osteoporosis, was discharged to home with family. Her Discharge MDS assessment did not reflect any falls, despite the care plan indicating that she had experienced falls on two occasions: once while self-transferring from the restroom to bed, resulting in a laceration below the chin, and another time with discoloration to the eyebrow, which the resident attributed to a fall in the restroom. Interviews with the MDS/LVN Coordinator and the DON confirmed that the falls should have been captured in the Discharge MDS assessment if they occurred within the look-back period. The facility's policy requires comprehensive assessments at designated intervals, and all persons completing any portion of the MDS must attest to the accuracy of the information. The failure to document the falls in the Discharge MDS could lead to improper care due to inaccurate records.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who reported her wallet missing. The resident, who had no cognitive impairment and was able to communicate effectively, reported the missing wallet to the Administrator. However, the grievance form was incomplete, lacking details such as the person investigating, the Administrator's signature, and the resolution. The resident stated she was not informed about the investigation, except that a police report was made. Interviews with the Administrator and the Director of Nursing (DON) revealed that the grievance was resolved when it was discovered that the resident's son had the wallet. However, the Administrator admitted to not filling out the grievance form. The DON explained that grievances were documented in binders at each nurse's station and discussed in morning meetings, but the responsibility for completing the grievance depended on its nature. The facility's grievance policy indicated that grievances should be filed within a specific time frame, but the incomplete documentation suggested a lack of adherence to this policy.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically addressing the need for oxygen therapy. The resident, a male with a diagnosis of pneumonia and severely impaired cognition, was prescribed continuous oxygen therapy at 2 liters per minute via nasal cannula. Despite this prescription, the resident's care plan did not include oxygen therapy, and the quarterly MDS assessment did not mark oxygen use. This oversight was identified during a record review and observation, where the resident was seen using oxygen without it being documented in the care plan. Interviews with facility staff, including the ADON, MDS nurse, and DON, revealed a lack of coordination and responsibility in updating the care plan to include oxygen therapy. The MDS nurses were identified as responsible for updating care plans, but the omission was not caught during the facility's morning meetings or by the charge nurses who input physician orders. The facility's policy requires that a comprehensive care plan be developed within seven days of the resident's comprehensive assessment, but this was not adhered to, leading to the deficiency.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with severe cognitive impairment and multiple medical conditions including obstructive and reflux uropathy, was observed with his urinary catheter bag touching the floor. This situation was identified during an interview and observation, where the resident mentioned recent discomfort due to a blocked catheter. The facility's policy requires catheter tubing and drainage bags to be kept off the floor to prevent infection. Interviews with staff, including an LVN and the DON, revealed inconsistencies in catheter care practices. The LVN acknowledged the catheter bag should be hung and corrected the situation upon observation. The DON mentioned that while the catheter system is closed, contact with the floor could pose a risk if the system is open. Another LVN confirmed the risk of infection if the catheter bag touches the floor, emphasizing the importance of immediate correction. Despite these acknowledgments, the facility's failure to consistently adhere to its catheter care policy resulted in a potential risk for cross-contamination and urinary tract infections.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day notice of discharge to a resident and their representative before the resident was discharged home. The resident, a male with multiple health conditions including a heart attack, diabetes, and heart disease, was discharged without the required notice. The resident's family member was informed of the discharge only a few days prior, and the discharge was executed due to financial reasons and non-compliance with the Medicaid application process. The resident's family member had been asked multiple times to provide bank statements necessary for the Medicaid application, but she refused, stating she did not intend for the resident to stay long-term. Despite the facility's attempts to obtain the necessary documentation, the family member did not comply, leading to a significant outstanding balance. The facility decided to discharge the resident due to the financial situation and the family's indication that they would take the resident home. Interviews with facility staff, including the Social Worker, BOM, and Administrator, revealed a lack of clarity and communication regarding the discharge process and the necessity of a 30-day notice. The staff believed that the discharge was mutually agreed upon due to the financial circumstances, but the required notice was not provided. The facility's policy did not explicitly include the requirement for a 30-day discharge notice, contributing to the oversight.
Failure to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after hospitalization, violating their written policy on permitting residents to return after hospitalization or therapeutic leave. The resident, a male with a history of hypertensive heart disease, vascular dementia, and major depressive disorder, was initially admitted to the facility in 2020. He exhibited physical and verbal behavioral symptoms, including aggression towards other residents and staff, and had a history of refusing medications. Despite these challenges, the facility had a care plan in place to manage his behaviors, including psychological assessments and various interventions to alleviate his anxiety and aggression. The resident was sent to the hospital after an incident where he hit a female resident in the face. The hospital cleared him for return, but the facility refused to re-admit him, citing his aggressive behavior and refusal to take medications as reasons. The facility had issued a 30-day discharge notice prior to the hospitalization, stating that they could not meet his needs and that he was a threat to the health and safety of other residents and staff. The resident's responsible party had appealed this discharge notice, and a hearing was scheduled, but the facility still refused to re-admit him after his hospital stay. Interviews with the Director of Nursing (DON), a Med Aide, and the hospital staff confirmed the resident's aggressive behavior and refusal to take medications. The facility's policy stated that residents should not be transferred or discharged while an appeal is pending unless their presence endangers the health or safety of others. Despite this policy, the facility did not allow the resident to return, citing multiple incidents of aggression and the inability to manage his care needs as justification for their decision.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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