Gainesville Convalescent Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gainesville, Texas.
- Location
- 1900 O'neal St, Gainesville, Texas 76240
- CMS Provider Number
- 675067
- Inspections on file
- 34
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Gainesville Convalescent Center during CMS and state inspections, most recent first.
Surveyors found that two residents with significant physical and cognitive impairments, incontinence, and need for assistance with personal care were left with visibly soiled washable incontinent pads on their beds, including yellow staining on one pad and red staining on another. A CNA could not recall when one resident’s linens were last changed and acknowledged she had not yet changed the soiled bedding after getting the resident up, while another resident’s pad with red stains had last been changed the prior day and had not been noticed as dirty. Nursing staff described expectations that linens be changed on shower days and when visibly soiled, and that incontinent pads be changed with each incontinent episode, while leadership stated soiled linens could affect dignity and infection control and confirmed there was no written policy governing bed linen cleanliness.
The facility failed to complete and update comprehensive, IDT-developed care plans to reflect therapeutic diet needs for two residents. One resident with muscle wasting, hypothyroidism, hypotension, and type 2 DM had an MDS indicating a therapeutic diet, but his baseline and comprehensive care plans listed only a regular diet with thin liquids and a single care area for code status. Another resident with HTN, renal failure, DM, and IBS had an order for a controlled carbohydrate diet and an MDS noting a therapeutic diet, yet her baseline and comprehensive care plans also showed only a regular diet with thin liquids and code status. The MDS nurse acknowledged being behind on care plan completion and confirmed that these care plans were incomplete, and the report states this could place residents at risk of not receiving appropriate interventions.
A resident with muscle weakness, muscle wasting, depression, and documented need for assistance with personal care did not receive consistent help with bathing and grooming. Records showed only three showers and one documented refusal over a multi-week period, with no documentation for two scheduled shower days. On observation, the resident wore stained clothing and had visible facial hair, and reported that requests for shaving and showers were often ignored. CNAs and nursing leadership confirmed expectations that residents be showered and shaved on scheduled days and upon request, with refusals documented, but could not account for the missed showers or lack of documentation, despite a facility policy requiring assistance with hygiene for residents unable to perform ADLs independently.
Surveyors found that the facility failed to follow therapeutic diet orders for two residents. One resident with muscle wasting, hypotension, hypothyroidism, and type 2 DM had an active order for a fortified food plan but continued to receive a low concentrated sugar/controlled carbohydrate diet with smaller portions and fewer calories, as shown on diet tickets and confirmed by the Dietary Manager, who reported not being notified of the diet change. Another resident with HTN, renal failure, DM, and IBS had an order for a controlled carbohydrate (low concentrated sugar) diet but received regular, unrestricted meals with standard portions of carbohydrates, sugar, and desserts, as evidenced by saved meal tickets labeled regular diet and acknowledged by the Dietary Manager. The DON and ADON described that diet changes from the physician, dietitian, or therapist should be communicated to dietary, and the facility’s policy required therapeutic diet orders to align with food and nutrition services terminology.
Multiple residents experienced deficiencies in their bathrooms, including missing tiles, exposed wires, non-functioning toilets, and rusted handrails. These issues were not addressed in a timely manner, despite facility policies requiring a safe and homelike environment, resulting in unsafe and uncomfortable conditions for residents.
A resident with a history of DVT, atrial fibrillation, and other serious conditions requested to be sent to the hospital due to leg pain and shortness of breath. The assigned RN failed to assess the resident, notify a physician, or facilitate the transfer, instead calling the police for behavioral concerns without mentioning the medical request. The police ultimately called EMS, who transported the resident to the hospital for evaluation and treatment. This failure to act on the resident's request and change in condition constituted neglect.
A resident with a history of DVT, atrial fibrillation, and pulmonary edema reported shortness of breath and leg pain, requesting to go to the hospital. The assigned RN did not assess the resident or notify the physician, and did not facilitate the transfer, instead calling the police after a verbal altercation. Other staff were aware of the RN's failure to provide care but did not immediately report the potential neglect to the Abuse Coordinator. The resident was ultimately transported to the hospital by EMS after police intervention. The facility failed to ensure immediate reporting and response to the alleged neglect, resulting in the RN continuing to work additional shifts after the incident.
A resident with a history of DVT and other serious conditions requested to be sent to the hospital due to worsening leg pain and shortness of breath. The assigned RN did not assess the resident, notify the physician, or initiate hospital transfer, and instead called the police after a verbal altercation. The police subsequently contacted EMS, who transported the resident to the hospital. Facility staff and the DON were not informed of the resident's request or transfer in a timely manner, resulting in a failure to honor the resident's right to self-determination and a dignified existence.
A nurse failed to notify a resident's physician when the resident experienced shortness of breath and leg pain and requested to go to the hospital. The nurse did not assess the resident or communicate the change in condition to the physician or facility leadership. The situation escalated, leading to police and EMS involvement, and the resident was transported to the hospital without proper notification or documentation.
The facility's kitchen staff failed to follow food safety standards, with Dietary Aides not wearing effective hair restraints and neglecting hand hygiene during meal service. These actions risked food contamination, as confirmed by the Dietary Manager.
A facility failed to maintain a functional bathroom sink for three residents, leading to unsanitary conditions. Despite being aware of the issue since May, the maintenance department did not resolve the problem, affecting the residents' ability to perform basic hygiene tasks. The Maintenance Director acknowledged the ongoing problem and indicated the need for a plumber, but no action was taken. Staff were aware of the issue, attributing it to pencil shavings being disposed of in the sink.
The facility failed to develop comprehensive care plans for residents, neglecting to specify psychotropic medications, ADL assistance, and discharge goals. Significant weight loss in two residents was not addressed in their care plans, and contractures in another resident were overlooked. Additionally, preferences for same-sex staff assistance during showers were not documented, leading to refusals of care.
A facility failed to provide individualized and group activities for three residents on a secure unit, impacting their quality of life. One resident with dementia lacked an activity care plan despite his interest in socializing and hands-on activities. Another resident with cognitive impairment and wandering behavior did not receive activities per his preferences, and there was no communication with his family. A third resident with vascular dementia and violent behavior also lacked an individualized activity care plan, despite the facility's policy emphasizing the importance of such activities.
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in oxygen therapy management. A resident was observed receiving continuous oxygen therapy without a physician's order, and another resident did not have her nasal cannula, oxygen tubing, and humidifier changed as per orders. Additionally, two residents had empty humidifier bottles that were not replaced in a timely manner, indicating a breakdown in communication and process.
The facility failed to provide RN coverage for at least 8 consecutive hours daily on weekends in June, July, and August 2024, leaving staff without supervisory support for RN-specific activities. Interviews confirmed the absence of RN coverage, with the ADON, an LVN, being contacted for assistance, potentially placing her out of her scope of practice. The facility began using agency RNs in September 2024 to address the issue.
A resident with a surgical incision did not receive proper wound care due to the facility's failure to follow physician orders. The ADON did not discontinue an outdated xeroform dressing order, leading to conflicting orders. An Agency LVN applied both xeroform and wet to dry dressings without notifying the ADON, DON, or Physician. The resident, with severe cognitive impairment and multiple health issues, was at risk due to this oversight.
A resident with a history of stroke and other conditions did not have a timely care plan meeting involving an interdisciplinary team, as required by facility policy. The resident expressed a desire to be involved in her care and discharge planning, but the meeting was overdue. The facility's policy mandates a comprehensive care plan within 21 days of admission.
A resident with severe cognitive impairment and Alzheimer's was not provided with necessary grooming services, including facial hair removal and nail trimming, despite being scheduled for showers. The CNA responsible overlooked these tasks and did not report the resident's refusal to the nurse, contrary to facility policy. The DON emphasized the importance of maintaining resident dignity through proper grooming.
A resident with schizoaffective disorder and bipolar disorder was admitted without a PASARR Level 2 evaluation, as required. The PASARR Level 1 Screening incorrectly indicated no mental illness, despite the resident's significant psychiatric history. The MDS Nurse was unfamiliar with the PASARR process, leading to the oversight, which was later confirmed by the Regional Reimbursement Coordinator.
A resident with a G-tube did not receive proper medication administration as the LVN failed to flush the tube with water before and after medications, did not dissolve medications properly, and used a plunger to push medications through the tube. The LVN also allowed the tube to drain completely between medications, contrary to facility policy. Interviews revealed a lack of awareness of proper procedures.
An LPN in a LTC facility failed to disinfect a blood pressure cuff between resident checks and did not perform hand hygiene during medication administration. The LPN also mishandled medications by touching them with bare hands and not sanitizing medication bottles after they fell. These actions were against the facility's infection control policies, as confirmed by the DON.
A resident with a history of smoking was not offered the opportunity to smoke during designated breaks, despite being assessed as a safe smoker. The resident was unaware of her right to smoke, and staff were not informed of her smoking status. Her smoking items were stored in the nurse's narcotic medication cart, and she was not listed on the facility's smoking resident list, indicating a communication breakdown.
The facility failed to promptly address grievances related to air conditioning issues for four residents, who experienced discomfort due to inadequate room temperatures. Despite having a grievance policy, no grievances were recorded, and residents had to rely on family or personal funds to purchase window AC units. The facility's staff provided conflicting accounts of grievance handling, indicating a lack of proper documentation and resolution.
A resident with cognitive impairments experienced an unwitnessed fall and showed signs of pain, but did not receive timely pain management. There was a nine-hour delay in administering prescribed medication, and the resident's pain increased, leading to hospitalization for a hip fracture. The facility failed to assess and manage the resident's pain effectively, resulting in significant discomfort and the need for surgery.
A resident with a history of cognitive deficits experienced an unwitnessed fall, leading to a delay in receiving a STAT x-ray for a suspected hip fracture. Despite increasing pain, the x-ray order was initially placed as routine, and staff failed to follow up promptly. The resident was eventually sent to the hospital, where a hip fracture was diagnosed. Interviews revealed a lack of training and policy for x-ray services, contributing to the delay.
The facility failed to implement its abuse prevention policy, resulting in delayed reporting of a resident's serious injury and an unreported abuse allegation. Additionally, a staff member's background checks were not completed upon hire, posing a risk to residents.
The facility failed to report abuse and neglect incidents within the required timeframe for two residents. A resident with a history of traumatic brain injury experienced a fall with a serious injury, but the incident was reported late to HHSC. Another resident was allegedly pulled from a chair by an LVN, causing a fall, but the incident was not reported until the next day. The facility's policy requires such incidents to be reported within two hours, but both were delayed.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and bipolar disorder, did not have a comprehensive care plan addressing his behaviors and preferences. Despite incidents involving vapes and alcohol, and verbal abuse towards staff, these issues were not reflected in his care plan. Staff interviews revealed the resident's challenging behaviors and the facility's failure to update the care plan accordingly.
A CNA failed to perform proper hand hygiene during incontinence care for a resident with hemiplegia and moderate cognitive impairment. The CNA did not change gloves or sanitize hands between handling soiled and clean items, contrary to facility policy. This lapse in infection control was acknowledged by both the CNA and the DON, highlighting a risk of cross-contamination.
The facility failed to maintain a clean and sanitary environment on Hall 300, as observed by a strong urine smell and unsanitary conditions in a resident's room and shared bathroom. Housekeeping was disrupted when the assigned housekeeper was reassigned to laundry, leaving the hall uncleaned. The facility's policy emphasizes cleanliness, which was not upheld in this instance.
Failure to Maintain Clean Bed Linens and Incontinent Pads for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring clean bed linens for two residents. Surveyors observed that on 2/17/26, the beds of Resident #3 and Resident #4 had visibly soiled washable incontinent pads in place. The facility did not have a policy for bed linens or overall facility cleanliness when requested by the Administrator. Resident #3 was an older female with muscle wasting and atrophy, muscle weakness, need for assistance with personal care, depression, moderate cognition with a BIMS score of 10, and bowel and bladder incontinence. On observation of her bed at 9:59 a.m., the incontinent pad had a yellow stain on the lower right side, approximately 4 inches long and 3 inches wide in an oval shape. CNA A, when interviewed at 10:06 a.m., did not recall when she last changed Resident #3’s sheets and incontinent pad, acknowledged the stain, and stated she had gotten the resident up and ready but had not yet changed the sheets. She stated that not changing dirty sheets could lead to the spread of infection. Resident #4 was an older male with Huntington’s disease, need for assistance with personal care, urinary tract infections, and post-traumatic stress disorder, with severe cognitive deficits and a BIMS score of 7. He required substantial assistance with toileting and was occasionally incontinent of bladder. At 10:03 a.m., his bed was observed with an incontinent pad that had two small red circles on the right side, which CNA A stated looked like blood; she reported last changing his bed sheets the previous day and said she typically changed pads when she saw they were dirty but had not noticed this one. LVN C reported she had not been in Resident #4’s room since her shift began and had not checked his bed linens. CNA B stated linens should be changed on shower days or when visibly soiled, and the ADON stated incontinent pads should be changed with every incontinent care episode and that dirty sheets put residents at risk of skin breakdown. The DON and Administrator both stated linens should be changed when visibly soiled and on shower days, and that soiled linens could affect residents’ dignity and infection control, while also confirming there was no facility policy on bed linens or cleanliness.
Incomplete Comprehensive Care Plans for Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive, person-centered care plans were completed, and reviewed and revised by the interdisciplinary team to reflect current needs, specifically related to therapeutic diets for two residents. For Resident #1, a male with muscle wasting and atrophy, hypothyroidism, hypotension, and type 2 diabetes, the Initial MDS assessment documented that he was cognitively intact with a BIMS score of 14 and required a therapeutic diet on admission and while a resident. His Baseline Care Plan dated 1/9/26 listed a regular diet with thin liquids, and his Comprehensive Care Plan Report dated 1/21/26 consisted of only one completed care area related to code status, with no care area addressing his need for a therapeutic diet. The facility’s policy stated that comprehensive, person-centered care plans are to be based on resident assessments and developed by an IDT according to the timeframes and criteria in §483.21. For Resident #2, a female with hypertension, renal failure, diabetes mellitus, and irritable bowel syndrome, the Initial MDS assessment showed she was cognitively intact with a BIMS score of 15 and noted a therapeutic diet while a resident. Her Order Summary Report reflected an order for a controlled carbohydrate diet starting 1/30/26, but her Baseline Care Plan for that date listed a regular diet with thin liquids. Her Comprehensive Care Plan Report, dated 1/21/26, similarly contained only one completed care area related to code status and did not include her therapeutic diet needs. In interviews, the MDS Nurse Coordinator acknowledged responsibility for completing comprehensive care plans, stated she was behind on completing care plans for new admissions, and confirmed that the care plans for both residents were incomplete and lacked therapeutic diet information. The report states that this deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.
Failure to Provide Required Bathing and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically bathing and grooming, to a resident who required help. The resident was an adult female with muscle wasting, muscle weakness, a need for assistance with personal care, depression, and upper and lower extremity limitations bilaterally. Her Quarterly MDS showed moderate cognition with a BIMS score of 10 and documented that she required partial/moderate assistance for showers and baths, and supervision for personal hygiene including shaving. Review of shower records from February 1 to February 17, 2026, showed she received showers on three dates and refused one shower, but there was no documentation of showers or refusals on two of her scheduled shower days. On observation, the resident was noted to be wearing stained and dirty clothing and had significantly visible facial hair on her chin. During interviews, the resident reported that she frequently asked staff to shave her facial hair and for showers, but staff often ignored her requests, and she could not recall the last time her chin hair was shaved or when she last had a shower. CNA A acknowledged the resident’s visible facial hair, could not recall when she last bathed or shaved the resident, and stated the resident’s shower days were three times per week, but she did not recall if she had bathed the resident on the most recent scheduled days. CNA B stated that residents are offered showers multiple times if they initially refuse and that grooming is required with each shower unless refused. The ADON and DON both stated that residents should receive showers and shaving on scheduled days and upon request, and that refusals should be documented, but the ADON confirmed there was no documentation of refusals for the missed shower days and could not explain why the showers did not occur. The facility’s ADL policy required appropriate support and assistance with hygiene, including bathing, dressing, grooming, and oral care, for residents unable to carry out ADLs independently.
Failure to Follow Therapeutic Diet Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed therapeutic diets consistent with physician orders for two residents. One male resident with intact cognition, muscle wasting and atrophy, hypothyroidism, hypotension, and type 2 diabetes was admitted on 1/9/26 and had an order dated 1/23/26 for a Fortified Food Plan Diet with regular texture and liquids. His Initial MDS documented a therapeutic diet on admission and while a resident. However, his breakfast ticket dated 2/16/26 listed a Low Concentrated Sugar/Consistent or Controlled Carbohydrates diet instead of the ordered fortified food plan. On 2/17/26, surveyors observed an untouched breakfast tray in his room containing sausage, an egg-like item, oatmeal, French toast with syrup, and juice, with the tray ticket again reflecting a Low Concentrated Sugar/Consistent or Controlled Carbohydrate diet rather than the ordered fortified diet. The Dietary Manager stated on 2/17/26 that she had been providing this resident a Low Concentrated Sugar diet and only then noticed that the physician had changed the diet to a Fortified Food Plan requiring larger portions and more calories. She reported she did not recall receiving notification of the diet change from nursing or the dietitian and acknowledged that the Low Concentrated Sugar diet provided smaller portions and fewer calories than the ordered fortified plan. The DON later stated that it was the dietitian’s responsibility to notify the Dietary Manager of changes in therapeutic diets and believed the diet for this resident was not changed timely because a new dietitian had sent an incomplete spreadsheet of residents on therapeutic diets. A second female resident with intact cognition, hypertension, renal failure, diabetes mellitus, and irritable bowel syndrome was admitted on 1/30/26 with an order dated 1/30/26 for a Controlled Carbohydrate (Low Concentrated Sugar) diet, and her Initial MDS also documented a therapeutic diet. Her lunch tickets dated 2/9/26 and 2/10/26 showed a Regular Diet instead of a controlled carbohydrate/diabetic diet. She told surveyors she had been receiving regular portions of carbohydrates, regular sugar, and desserts, and produced saved meal tickets labeled Regular Diet. On 2/17/26, her lunch tray ticket finally reflected a Low Concentrated Sugar/Controlled Carbohydrate Diet, and the observed meal contained smaller portions and sugar substitutes. The Dietary Manager confirmed that when a ticket reflects “regular” there are no dietary restrictions, that diabetic residents should receive a Low Concentrated Sugar diet, and that this resident’s orders had always reflected a Low Concentrated Sugar diet, but she had been receiving regular meals. The ADON stated that diet orders from the speech therapist, dietitian, or physician should be given to the Dietary Manager as soon as they are changed. The facility’s Therapeutic Diets policy required that therapeutic diets be prescribed by the attending physician or delegated dietitian and that diet orders match the terminology used by food and nutrition services.
Failure to Maintain Safe and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed in resident bathrooms. For one resident with coronary artery disease and heart failure, who was independent with toileting, the bathroom tile around the toilet was missing, exposing rocks, and this condition had persisted since June. Another resident, who was dependent with activities of daily living, had a bathroom with a non-functioning toilet and exposed wires from a fan blower in the ceiling; these issues had been present since the resident's admission and for at least a week, respectively. Additionally, shared bathrooms connecting several resident rooms were found to have rusted handrails next to the toilets. The rust was observed around the lower part of the handrails where they attached to the wall, with varying degrees of rust in different bathrooms. The Maintenance Director was not previously aware of the rusted handrails and stated that he was responsible for their repair or replacement. Staff interviews confirmed that repairs could be reported through a QR code system, but the rusted handrails had not been reported or addressed prior to the survey. Facility policies reviewed indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards, and that residents are to be provided with a safe, clean, and homelike environment. Despite these policies, the observed deficiencies in bathroom maintenance and repair, including missing tiles, exposed wires, non-functioning toilets, and rusted handrails, were not addressed in a timely manner, resulting in an environment that did not meet the required standards for resident safety and comfort.
Failure to Protect Resident from Neglect Following Request for Hospital Transfer
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to protect a resident's right to be free from neglect. The resident, who had a history of acute embolism, thrombosis, atrial fibrillation, chronic pulmonary edema, and peripheral vascular disease, reported to the RN that he needed to go to the hospital due to leg pain and shortness of breath. The RN did not perform an assessment, did not notify a physician or another licensed nurse, and did not facilitate the resident's transfer to the hospital. Instead, the RN called the police to report the resident's behavior, omitting the resident's request for hospital transfer. When the police arrived, the RN again failed to inform them of the resident's request to go to the hospital. The police, upon interacting with the resident and noting his symptoms, called EMS, who then transported the resident to the emergency room. The resident was subsequently admitted to the hospital and placed on a heparin drip as a precaution for possible deep vein thrombosis (DVT), pending further tests. Interviews and record reviews confirmed that the RN did not communicate the resident's request or change in condition to the appropriate medical personnel, and other staff members did not immediately report the neglect to facility leadership as required by policy. The resident was cognitively intact and able to communicate his needs, including his desire to be sent to the hospital. Multiple staff interviews corroborated that the RN had a pattern of avoiding care for this resident and delegating medication administration to other nurses. The failure to assess, notify, and act on the resident's request for hospital transfer constituted neglect, as the resident's medical needs and rights were not addressed in a timely or appropriate manner.
Failure to Timely Report and Respond to Alleged Neglect of Resident Requesting Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by regulation. Specifically, a resident with a history of acute embolism, thrombosis, atrial fibrillation, and chronic pulmonary edema reported shortness of breath and leg pain, expressing concern for a possible blood clot and requesting to be sent to the hospital. The assigned RN did not assess the resident or notify the physician, and did not facilitate the resident's transfer to the hospital. Instead, the RN left the resident's room after a verbal altercation and called the police, citing fear for personal safety. The police, upon arrival, called EMS, who then transported the resident to the hospital for evaluation and treatment. Other staff members, including a CNA and an LVN, were aware that the RN had not provided care or facilitated the resident's request for hospital transfer, but did not immediately report this potential neglect to the facility's Abuse Coordinator or Administrator. The Director of Nursing (DON) was not informed of the resident's request to go to the hospital or the RN's refusal to provide care until days later. The resident was admitted to the hospital with symptoms consistent with his medical history, including worsening lower extremity edema, pain, and dyspnea, and was treated for possible DVT and pulmonary embolism. The facility's policy required immediate reporting of suspected abuse or neglect to the Administrator and appropriate authorities. However, the failure of the RN to provide care and the failure of other staff to report the incident in a timely manner resulted in the RN continuing to work additional shifts after the incident. The deficiency was identified as Immediate Jeopardy due to the risk of serious harm to residents, as staff did not follow established procedures for reporting and responding to allegations of neglect.
Failure to Honor Resident's Right to Self-Determination and Timely Hospital Transfer
Penalty
Summary
A deficiency occurred when a cognitively intact male resident, who was his own responsible party and had a significant medical history including acute embolism, thrombosis, atrial fibrillation, and chronic pulmonary edema, requested to be sent to the hospital due to worsening leg pain and shortness of breath. The resident had a documented history of deep vein thrombosis (DVT) and was at high risk for further complications. Despite his request and his ability to make his own medical decisions, the assigned RN did not facilitate his transfer to the hospital or notify the physician or Director of Nursing (DON) about his request or change in condition. The RN entered the resident's room after being informed that he wanted to speak with her. Upon being told by the resident that he needed to go to the hospital, the RN responded that he could go, but did not proceed with any assessment, further questioning, or initiation of the transfer process. The interaction escalated, resulting in the resident becoming verbally aggressive and the RN leaving the area and calling the police due to concerns for her safety. The RN did not inform the police, other staff, or facility leadership that the resident had requested to go to the hospital. The police, upon arrival, observed the resident's symptoms and contacted EMS, who then transported the resident to the hospital for evaluation and treatment. Interviews with facility staff, including the DON and other nurses, confirmed that the RN failed to notify appropriate personnel or take action to address the resident's request and symptoms. The DON was not made aware of the situation until days later, and the resident's physician stated that the nurse should have contacted EMS for transport as per protocol. The facility's policy on resident rights, which includes the right to self-determination and participation in care decisions, was not followed in this instance, resulting in a failure to honor the resident's rights and potentially compromising his dignity and quality of life.
Failure to Notify Physician of Resident Change in Condition and Hospital Transfer
Penalty
Summary
A deficiency occurred when a nurse failed to notify a resident's physician of a significant change in the resident's physical status and subsequent transfer to the hospital. The resident, who was cognitively intact and his own responsible party, had a complex medical history including acute embolism, thrombosis, atrial fibrillation, chronic pulmonary edema, and peripheral vascular disease. On the day of the incident, the resident reported shortness of breath and leg pain, symptoms consistent with his history of deep vein thrombosis, and requested to be sent to the hospital. The nurse did not assess the resident or gather further information about his symptoms, nor did she notify the physician or other facility leadership about the resident's request or change in condition. The situation escalated when the resident became verbally aggressive after feeling his concerns were dismissed. The nurse left the area and called the police, expressing concern for her safety but did not communicate the resident's medical complaints or his request to go to the hospital to the police, physician, or other staff. When police arrived, they observed the resident's symptoms and contacted EMS, who transported the resident to the hospital for evaluation of possible blood clots and shortness of breath. The nurse did not participate in the transfer process or provide necessary documentation for the resident's hospital transfer. Interviews with facility staff, including the DON and other nurses, confirmed that the physician was not notified of the resident's change in condition or hospital transfer. The DON and the resident's physician both stated that they expected the nurse to assess the resident, notify the physician, and facilitate the transfer if needed. The facility's policy required prompt notification of the physician for changes in a resident's condition and prior to hospital transfer, which was not followed in this case.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a lunch meal service. Dietary Aides J and K did not wear effective hair restraints, leaving portions of their hair uncovered while handling food. Specifically, Dietary Aide J had about 1.5 inches of hair uncovered at the back and 1 inch above both ears, while Dietary Aide K had about 0.5 inches of hair uncovered in various areas. These lapses in hair restraint could lead to hair contamination in the food being served to residents. Additionally, both Dietary Aides failed to perform proper hand hygiene during food preparation and service. Dietary Aide J was observed touching the counter and her apron without washing her hands before continuing to handle food and plates. Similarly, Dietary Aide K touched her face mask and continued to handle meal trays without washing her hands. These actions were contrary to the facility's policy on preventing foodborne illness, which requires handwashing after touching potentially contaminated surfaces. The Dietary Manager confirmed that these practices placed residents at risk for food contamination and illness.
Facility Fails to Maintain Functional Bathroom Sink for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for three residents by not ensuring the shared bathroom sink was in working order. The sink, shared by three residents, was clogged and unusable for an extended period, leading to unsanitary conditions. Despite being aware of the issue since May 2024, the maintenance department did not resolve the problem, and the sink remained clogged, affecting the residents' ability to perform basic hygiene tasks such as washing their hands and faces. Resident #19, who had intact cognition despite her dementia diagnosis, reported the issue to the maintenance department and the Director of Nursing (DON). She observed the Maintenance Director attempting repairs multiple times without success. Resident #45 also reported the problem, noting that the sink was unusable and that she had to use alternative methods for personal hygiene. Resident #9 expressed her discomfort with the situation, stating that she avoided using the sink to prevent further issues. The Maintenance Director acknowledged the ongoing problem and indicated that he had informed the previous administrator about the need for a plumber, but no action was taken. The facility's maintenance log showed an entry about the clogged sink, but subsequent issues were not documented. Interviews with staff, including the Housekeeping Manager and the DON, revealed that they were aware of the problem and attributed it to pencil shavings being disposed of in the sink. Despite multiple attempts to address the issue, the sink remained clogged, compromising the residents' living conditions and hygiene.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For instance, Resident #50's care plan did not specify the psychotropic medications ordered, the specific ADL assistance required, or discharge goals. The resident expressed a desire to be involved in her care and was unaware of the facility's smoking break times or discharge plan options. The ADON acknowledged that a care plan meeting was overdue for this resident. Residents #43 and #46 experienced significant weight loss, yet their care plans did not reflect their ADL assistance needs or address the weight loss. Resident #46's dietary progress notes indicated variable intake and therapy involvement, but these were not incorporated into the care plan. Similarly, Resident #43 required assistance with all ADLs, but this was not documented in her care plan. Interviews with staff revealed confusion about responsibilities for care planning, with the MDS Coordinator and ADON each believing the other was responsible for certain aspects. Resident #39's care plan failed to address contractures in his right hand or interventions to maintain skin integrity. Observations noted long and dirty fingernails, and the resident expressed discomfort with certain interventions. The MDS Coordinator acknowledged the need for care planning around contractures and nail care. Additionally, Residents #7 and #28's preferences for female staff to assist with showers were not documented in their care plans, leading to refusals of care. Interviews with staff confirmed awareness of these preferences, but they were not reflected in the care plans.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized and group activities for three residents on the secure unit, which could potentially impact their quality of life and psychosocial well-being. Resident #13, a male with multiple diagnoses including dementia and cognitive communication deficit, did not have an activity care plan despite his interest in socializing, walking, and engaging in activities with his hands. Observations revealed that he was often seen pacing and mimicking fixing things, indicating a lack of suitable activities to meet his preferences. Resident #26, also severely cognitively impaired, exhibited wandering behavior and had preferences for outdoor activities and using his hands. However, the facility did not follow his individualized activity care plan, and he was often seen pacing with no activities provided. The Activity Director (AD) did not engage him in individualized activities, and there was a lack of communication with his family to understand his preferences better. Resident #36, a female with vascular dementia and violent behavior, did not have an individualized activity care plan. She was on hospice services and exhibited behaviors such as hallucinations and delusions. The AD acknowledged that music could be beneficial for her, but there was no evidence of activities being provided to meet her needs. The facility's policy on activity programs emphasized the importance of individualized activities, but this was not reflected in the care provided to these residents.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in oxygen therapy management. Resident #37, who was cognitively intact and had a history of respiratory issues, was observed receiving continuous oxygen therapy without a physician's order for such treatment. The resident's oxygen concentrator was set incorrectly at different times, and the staff responsible for monitoring the oxygen levels admitted to assuming the order was in place without verifying it. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of having specific orders for continuous oxygen therapy. Resident #25, also cognitively intact, did not have her nasal cannula, oxygen tubing, and humidifier changed as per physician orders. The staff member responsible for this task admitted to signing off on the medication administration record before completing the task and then forgetting to return to it. This lapse in protocol was not communicated to the oncoming shift, leaving the resident with outdated equipment, which the resident herself noted was overdue for replacement. Residents #28 and #253 experienced similar issues with their oxygen therapy equipment. Both residents had empty and undated humidifier bottles, which were not replaced in a timely manner. Staff interviews revealed a lack of awareness and communication regarding the status of the humidifier bottles. The Assistant Director of Nursing found that there were supplies available, but they were not utilized, indicating a breakdown in the process of ensuring residents received the necessary respiratory care as ordered.
Failure to Provide RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required by regulations. This deficiency was identified through interviews and record reviews, which revealed that there was no RN coverage on several weekends in June, July, and August 2024. Specifically, the facility lacked RN coverage on weekends such as 06/01/24 - 06/02/24, 06/08/24 - 06/09/24, and others listed in the report. The absence of RN coverage on these weekends left the staff without supervisory support for RN-specific nursing activities, potentially affecting the care provided to residents. Interviews with various staff members, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Licensed Vocational Nurses (LVNs), confirmed the lack of RN coverage on weekends. The ADON, who is an LVN, was contacted for assistance during these times, which could place her out of her scope of practice. The DON confirmed that she did not provide weekend coverage and that the facility had started using agency RNs in September 2024 to cover weekends. The facility's policy requires a licensed nurse to be on duty 24/7 and an RN to provide services for at least 8 consecutive hours daily, which was not adhered to during the specified period.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow physician orders for wound treatment for a resident with a surgical incision on the right lower leg. The Assistant Director of Nursing (ADON) did not discontinue a previous physician order for a xeroform dressing when a new order for a wet to dry dressing was issued. This oversight led to conflicting orders being present in the resident's care plan. An Agency Licensed Vocational Nurse (LVN) failed to notify the ADON, Director of Nursing (DON), or Physician about the conflicting orders and proceeded to apply both a xeroform and a wet to dry dressing on the resident's incision site. The resident, who was severely cognitively impaired and had a history of hypertension, dementia, Parkinson's disease, and infection following a surgical procedure, was at risk due to this error. The LVN acknowledged the confusion caused by the conflicting orders but did not take the necessary steps to resolve the issue by consulting with the Nurse Practitioner or informing the DON. Interviews with the DON and the ADON revealed that the xeroform order should have been discontinued, and the responsibility for reviewing and updating orders weekly was with the ADON. The ADON admitted to missing the discontinuation of the xeroform order and did not perceive a risk to the resident, despite the potential for improper wound healing. The facility's wound care policy required verification of physician orders, which was not adhered to in this case.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to ensure that comprehensive care plans were prepared by an interdisciplinary team (IDT) that included the attending physician, a registered nurse, a nurse aide responsible for the resident, a member of the food and nutrition services staff, and the participation of the resident. This deficiency was identified for one of eight residents reviewed for care plan conferences. Specifically, Resident #50, a cognitively intact female with a history of stroke, cognitive communication deficit, diabetes, anxiety disorder, Alzheimer's disease, and seizures, did not have a care plan conference to discuss her treatment and discharge goals. The comprehensive care plan for Resident #50 lacked specific details regarding her psychotropic medications and the assistance required for activities of daily living (ADLs). Interviews revealed that Resident #50 had not been involved in a care plan meeting since her admission, and she expressed a desire to be informed and involved in her care, including discharge planning. The Assistant Director of Nursing (ADON) acknowledged that a care plan meeting should have been conducted within 21 days of admission and that Resident #50 was overdue for such a meeting. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission, ensuring resident participation and addressing their physical, psychosocial, and functional needs.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, a female with severe cognitive impairment and diagnoses of Alzheimer's and osteoarthritis, required moderate assistance for bathing and personal hygiene. Despite being scheduled for showers on specific days, the resident was observed to have long chin hairs and nails that were not trimmed, which she expressed dissatisfaction with. The resident was unaware that staff could assist with these grooming tasks. Interviews with staff revealed that the CNA responsible for the resident's care had overlooked the chin hair and had not successfully trimmed the resident's nails, despite attempts. The CNA did not report the resident's refusal to the nurse, which was against the facility's policy. The Director of Nursing confirmed that staff were expected to check and trim residents' nails daily and ensure facial hair was removed on shower days, emphasizing that failing to remove facial hair from a female resident is a dignity issue. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and hygiene.
Failure to Conduct PASARR Level 2 Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a new resident, identified as Resident #9, received a PASARR Level 2 evaluation upon admission, despite having diagnoses that included schizoaffective disorder and bipolar disorder. The resident's PASARR Level 1 Screening incorrectly indicated no evidence of mental illness, which was inconsistent with her medical history and diagnoses. This oversight was discovered during a review of the resident's records, which showed that she had been hospitalized in the past due to psychosis and had a significant psychiatric history. Interviews with the MDS Nurse revealed a lack of familiarity with the PASARR process and uncertainty about whether schizoaffective disorder or bipolar disorder qualified as mental illnesses for the PASARR Level 1 Screening. The MDS Nurse was responsible for entering data into the system and updating the MDS but was not working at the facility when the resident was admitted. The Regional Reimbursement Coordinator confirmed that the resident should have been referred for a PASARR Level 2 evaluation based on her diagnoses, and this should have been identified during quarterly MDS reviews.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a G-tube. The resident, who was severely cognitively impaired and dependent on all activities of daily living, required enteral nutrition due to conditions such as dehydration, dysphagia, and cerebral palsy. The facility did not ensure that the Licensed Vocational Nurse (LVN) followed the physician's orders to flush the G-tube with 30 cc of water before and after medication administration. During an observation, the LVN was seen preparing and administering medications to the resident without performing hand hygiene and using bare hands to handle medications. The LVN failed to dissolve all medications properly before administration and used a plunger to push undissolved medication through the G-tube, contrary to the facility's policy of administering medications by gravity. Additionally, the LVN allowed the G-tube to drain completely between each medication administration, which was against the facility's policy. Interviews with the LVN and the Director of Nursing (DON) revealed a lack of awareness and understanding of the proper procedures for G-tube medication administration. The LVN admitted to not knowing that medications should not be pushed through the tube and that the tube should not be allowed to empty completely between medications. The DON confirmed that the facility's policy required medications to be given by gravity and that improper administration could lead to complications such as tube displacement.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hygiene and sanitation practices by LVN A. During a medication pass, LVN A did not disinfect the blood pressure cuff between checks for three residents, nor did she perform hand hygiene before and after resident contact. This oversight was observed during the morning medication administration for three residents, including one who was cognitively intact and two who were severely cognitively impaired. Additionally, LVN A failed to adhere to proper medication handling protocols. She touched medications with her bare hands after they fell on the medication cart and did not sanitize medication bottles before placing them on a resident's bedside table. Furthermore, LVN A did not discard a bottle of eye drops after it fell on the floor, instead placing it back in the medication cart without sanitizing it. These actions were contrary to the facility's policies on hand hygiene and cleaning of resident-care items. The Director of Nursing confirmed that the staff were required to clean equipment and perform hand hygiene as per the facility's policies. Despite LVN A's previous training and validation in medication administration and infection control practices, she acknowledged her failure to follow these protocols, which could potentially lead to the spread of infections among residents.
Failure to Facilitate Resident's Smoking Preference
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for a resident reviewed for resident rights. The resident, a cognitively intact female with a history of stroke, cognitive communication deficit, diabetes, anxiety disorder, Alzheimer's disease, and seizures, was not offered the opportunity to smoke during designated smoke breaks. Despite being assessed as a safe smoker and having smoking materials, the resident was unaware of her right to smoke and had not been informed of the facility's smoking policy or break times. Interviews with facility staff revealed a lack of awareness regarding the resident's smoking status. The CNAs on the secure unit were not informed that the resident was a smoker, and her smoking items were not available on the unit. The ADON and DON were also unaware that the resident had not been offered the opportunity to smoke, despite her smoking items being stored in the nurse's narcotic medication cart. The facility's smoking resident list did not include the resident, indicating a communication breakdown and failure to adhere to the facility's smoking policy.
Failure to Address Resident Grievances on Air Conditioning
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to air conditioning issues for four residents. These residents, who had intact cognitive abilities, expressed discomfort due to inadequate room temperatures during the summer months. Despite the presence of a grievance policy, no grievances related to air conditioning or room temperatures were recorded in the grievance log from June to August 2024. Interviews with the residents revealed that they had to rely on family members or their own funds to purchase window air conditioning units to achieve a comfortable room temperature. The facility's maintenance staff installed these units, but the facility did not initially offer to provide them. The maintenance director acknowledged the facility's responsibility to ensure comfortable room temperatures and stated that window units should have been provided without delay. The Director of Nursing (DON) and the Administrator provided conflicting accounts regarding the handling of air conditioning grievances. The DON was unaware of who was responsible for purchasing window units, while the Administrator claimed that the facility offered window units to residents who requested them. However, the Administrator could not recall specific complaints or grievances related to air conditioning issues, indicating a lack of proper grievance documentation and resolution.
Failure in Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident following an unwitnessed fall. The resident, who had a history of traumatic brain injury, hypertension, and cognitive impairments, was found on the floor and exhibited signs of pain, such as mumbling and grumbling during transfer. Despite these indicators, the resident did not receive any pain management from the attending nurse, LVN A, immediately after the fall. There was a significant delay in administering pain medication to the resident, with a nine-hour gap before the resident received Tylenol 500 mg as per the physician's order. During this period, the resident showed increasing signs of pain, including facial grimacing, moaning, and holding her left hip. The attending nurse, LVN B, failed to follow the physician's order to administer the medication every four hours and did not notify the physician when the pain medication was ineffective. The lack of effective pain management resulted in the resident experiencing increased pain, leading to the intervention of the resident's power of attorney (POA) and the eventual hospitalization of the resident for a left displaced hip fracture. The facility's failure to assess, monitor, and manage the resident's pain in a timely manner placed the resident at risk of significant pain and discomfort, ultimately necessitating surgical intervention.
Delayed Radiology Services Lead to Resident's Hospitalization
Penalty
Summary
The facility failed to provide timely radiology services for a resident who experienced an unwitnessed fall, resulting in a significant delay in diagnosis and treatment. The resident, who had a history of traumatic brain injury, hypertension, and cognitive deficits, fell in the early hours and was found on the floor by staff. Despite the physician ordering a STAT x-ray for the resident's hips due to pain, the order was initially placed as routine, leading to a delay in the x-ray being performed. The resident continued to experience increasing pain throughout the day, and the x-ray results were not obtained in a timely manner. The nursing staff failed to follow up adequately on the x-ray order and did not escalate the resident's care despite her worsening condition. The resident's family expressed concern about the delay in receiving x-ray results and the resident's increasing pain, which eventually led to the resident being sent to the hospital, where a hip fracture was diagnosed. Interviews with staff revealed a lack of training and understanding regarding the urgency of STAT x-ray orders and pain management. The facility did not have a policy in place for x-ray services, and there was a failure to document and communicate effectively among the nursing staff and with the physician. This lack of timely intervention and follow-up placed the resident at risk for increased pain and delayed treatment.
Removal Plan
- Medical Director has been notified of the Immediate Jeopardy by the Administrator. QAPI was conducted with the medical director.
- Administrator/Designee initiated in-service on abuse and neglect.
- Regional Nurse to educate DON regarding assessing residents for pain after an incident, ordering STAT X-ray, completion, and follow-up of X-ray. Education includes obtaining order for X-ray, entering order in EHR/Matrix, sending the resident to the ER for evaluation if in-house X-ray cannot be obtained timely.
- DON/Designee initiated in-services with charge nurses/agency nurses on how to order a STAT X-ray, timely follow-up on X-rays related to X-ray completion and results which should be obtained within four hours when related to injury/pain, if longer than four hours resident(s) need to be transported to emergency room per physician's order.
- In-service charge nurses/agency nurses on notification to the DON/designee after hours and on weekends related to resident falls and results of pending X-rays initiated.
- Audit was completed on X-rays ordered in the last 30 days.
- Charge nurses, agency nurse/aides, and certified staff not working during the in-services on X-rays, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period.
- The weekend supervisor was in-service monitoring the Facility Activity Report and follow-up on orders i.e, X-ray, and residents with pain.
- Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by the weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall with major injury for timely completion of X-ray and results.
- Facility charge nurses and agency nurses will be given a competency-based quiz on following physician orders.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse prevention policy and investigate allegations of abuse for two residents and one staff member. The first incident involved a resident who sustained a serious injury of unknown origin. The facility's administrator did not report the injury within the required timeframe, which was a violation of the facility's policy. The resident, who had a history of falls and severe cognitive impairment, was found on the floor with hip pain. Despite the severity of the situation, the x-ray results indicating a hip fracture were not reviewed until the following day, and the incident was not reported to the state within the mandated two-hour window. In the second incident, a certified nursing assistant (CNA) failed to immediately report an allegation of abuse involving another resident. The CNA witnessed a licensed vocational nurse (LVN) pulling the resident from a chair by his legs, causing him to fall. The CNA did not report the incident until the next morning, citing a lack of contact information and the inability to leave the secured unit as reasons for the delay. This delay in reporting was contrary to the facility's policy, which requires immediate reporting of abuse allegations. Additionally, the facility did not complete the required criminal background check and Employee Misconduct Registry (EMR/NAR) check for an LVN upon hire. The absence of these checks in the employee's file posed a risk to residents, as it could allow individuals with a history of abuse to be employed at the facility. The HR manager admitted to not being aware of the missing checks and acknowledged the importance of completing these checks prior to employment. This oversight further highlights the facility's failure to adhere to its abuse prevention policies.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of abuse and neglect within the required timeframe for two residents. Resident #1, a female with a history of traumatic brain injury and other medical conditions, experienced a fall resulting in a serious injury. Despite the fall occurring at 12:17 AM on 02/24/2024, the incident was not reported to the Health and Human Services Commission (HHSC) until 9:10 AM on 02/25/2024, exceeding the mandated two-hour reporting window. The delay was attributed to the Director of Nursing (DON) not reviewing the critical x-ray results until the following morning, and the Administrator was unaware of the fracture until informed by the DON. Resident #8, a male with moderate cognitive impairment and multiple medical diagnoses, was involved in an incident where a Licensed Vocational Nurse (LVN) allegedly pulled him from a chair, causing him to fall. This incident occurred on 09/25/2023, but was not reported until the next morning. The delay was due to the Certified Nursing Assistant (CNA) witnessing the incident at the end of her shift and not having immediate access to report it. The facility's policy requires such incidents to be reported within two hours, but the report was delayed until the following day. The facility's failure to adhere to its abuse and neglect reporting policy, which mandates immediate reporting of such incidents to the Administrator and relevant authorities, resulted in these deficiencies. The policy specifies that allegations involving abuse or serious bodily injury must be reported within two hours, but both incidents were reported late, potentially placing residents at risk of further harm.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and person-centered care plan for a resident, identified as Resident #2, who was admitted with multiple diagnoses including unspecified dementia, bipolar disorder, chronic obstructive pulmonary disease, emphysema, and alcohol abuse. The care plan did not adequately address the resident's behaviors and preferences, particularly concerning his use of vapes and alcohol, and his verbal abuse towards staff and other residents. Despite multiple incidents of the resident being found with vapes and alcohol in his room, and his frequent use of profanity and racial slurs, these issues were not reflected in his care plan. Observations and interviews with staff revealed that Resident #2 often exhibited challenging behaviors, such as cursing at staff and other residents, and refusing care if it interfered with his preferred activities, like smoke breaks. Staff noted that the resident's family had previously smuggled alcohol and vapes into the facility for him. The resident's care plan, however, did not include strategies to manage these behaviors or address the risks associated with his use of vapes and alcohol. The facility's policy on care plans emphasizes the need for comprehensive, person-centered plans that include measurable objectives and timetables to meet residents' needs. However, the care plan for Resident #2 lacked these elements, failing to incorporate his behavioral issues and preferences. Interviews with the ADON and DON highlighted a lack of awareness and updates to the care plan, which should have included interventions and risk factors specific to the resident's needs.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during incontinence care for a resident. The resident, a male with a history of hemiplegia, muscle wasting, and cerebral infarction, required maximal assistance with toileting and personal hygiene due to moderate cognitive impairment and incontinence. During the care process, the CNA did not perform hand hygiene or change gloves appropriately, which is a critical step in preventing infection and cross-contamination. The CNA was observed cleaning the resident's pubic and buttock areas with peri-wipes, removing a soiled brief, and then placing a clean brief under the resident without changing gloves or sanitizing hands. After discarding the dirty gloves, the CNA donned clean gloves without performing hand hygiene, contrary to the facility's policy. Both the CNA and the Director of Nursing (DON) acknowledged the failure to follow proper hand hygiene protocols, which could place residents at risk for infection and cross-contamination.
Failure to Maintain Clean and Sanitary Environment on Hall 300
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on Hall 300. Observations revealed a strong smell of urine from a room, with a sheetless mattress on Bed B that had a wet circle and emitted a strong urine odor. Additionally, the shared bathroom for certain rooms was found to have dried feces on the toilet seat, no toilet paper, and loose paper on the floor in front of the sink. These conditions were observed twice on the same day, indicating a lack of cleanliness and sanitation in the environment provided to the residents. Interviews with facility staff revealed that the housekeeping schedule was disrupted on the day of the observations. CNA G mentioned that housekeeping typically cleaned the unit twice daily. However, Housekeeper A, who was responsible for cleaning Hall 300, was reassigned to the laundry room by the Maintenance Director, leaving the hall uncleaned. The Housekeeping Supervisor confirmed that she had to leave early that day and was unaware that Housekeeper A was reassigned, which resulted in the secure unit not being cleaned as expected. The facility's policy on providing a homelike environment emphasizes cleanliness and order, which was not maintained in this instance.
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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