Grace Care Center Of Henrietta
Inspection history, citations, penalties and survey trends for this long-term care facility in Henrietta, Texas.
- Location
- 807 W Bois D Arc, Henrietta, Texas 76365
- CMS Provider Number
- 455893
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Grace Care Center Of Henrietta during CMS and state inspections, most recent first.
Surveyors found that two outdoor dumpsters were overflowing with bagged garbage stacked above the rim, lids left open, and multiple trash bags and cardboard boxes on the ground. A CNA reported that staff routinely piled trash on top of full dumpsters or left it on the ground and that the dumpsters had not been emptied in weeks, despite concerns being reported to the Administrator. The Maintenance Director stated the dumpsters were not being collected due to nonpayment, acknowledged responsibility for trash on the ground, and admitted he had not recently hauled trash to the landfill. Both the Maintenance Director and Administrator recognized that the overflowing, uncovered dumpsters could attract pests.
The facility did not ensure complete and accurate documentation of insulin administration and blood glucose monitoring for four diabetic residents. Nurses failed to record insulin doses, blood sugar results, and meal announcements as ordered, with missing entries on multiple occasions. Staff interviews confirmed inconsistent documentation practices and uncertainty about whether required care was provided, despite facility policy requiring thorough recordkeeping.
The facility failed to pay vendors and maintain essential services, resulting in disconnected phone and internet, an uninsured and unregistered van, and staff purchasing supplies out of pocket. Residents missed medical appointments, and staff had to substitute food and laundry supplies due to insufficient funds. Communication with families and providers was severely impacted, and the absence of an administrator contributed to ongoing operational failures.
The facility operated without a state-licensed administrator for an extended period, resulting in unpaid vendor bills and the loss of essential services such as phone, internet, food, and laundry. Staff, including the DON and maintenance director, used personal funds to purchase supplies for residents. The lack of van insurance and registration led to missed medical appointments for several residents, and communication with families and providers was severely disrupted. These failures led to Immediate Jeopardy due to the widespread impact on resident care and facility operations.
The facility did not ensure proper laundering of resident linens due to a broken hot water heater, lack of required sanitizing chemicals, and inability to service the washing machine, all stemming from unpaid vendor bills. Staff used non-standard cleaning products, and observations confirmed that linens remained stained and odorous after washing. Multiple staff and the DON were aware of the ongoing issue, while the CEO was not informed until interviewed. The facility had 23 residents at the time.
A resident with a history of multiple myeloma and poly osteoarthritis experienced persistent, severe pain and requested hospice care, which was ordered by the facility physician. However, hospice services were delayed for eight days due to a facility policy requiring CEO approval before ancillary services could be initiated, despite repeated requests from the resident, her POA, and staff. The delay was administrative, not clinical, and was contrary to facility policy stating hospice should be made available at end of life.
The facility did not maintain a working telephone for resident use after phone service was disconnected due to non-payment. Residents and their families experienced ongoing difficulties in communication, with staff and the ombudsman confirming repeated complaints and failed attempts to reach the facility. The lack of phone access persisted until a staff member provided a prepaid cell phone at their own expense.
Several residents did not receive timely medical care or hospice services due to the facility's failure to maintain van registration and insurance, which prevented transportation to critical doctor appointments. Additionally, a resident's request for hospice care was delayed for several days because of a requirement for corporate approval, despite a physician's order and ongoing pain.
A resident with a history of bone cancer and poly osteoarthritis experienced ongoing, inadequately controlled pain due to an 8-day delay in arranging hospice services, which was caused by a requirement for CEO approval. During this period, pain assessments and medication administration were inconsistent, scheduled pain medication doses were missed, and communication with the physician regarding breakthrough pain was lacking, resulting in a failure to provide pain management consistent with professional standards and the resident's care plan.
The facility did not ensure RN coverage for at least 8 consecutive hours daily, 7 days a week, for several months. Staffing records and interviews confirmed that there was no RN present on multiple days, especially during the DON's medical leave and on weekends, with only phone availability as backup. A policy on RN coverage was requested but not provided.
Multiple residents did not receive their scheduled medications on time, with some missing entire doses, due to the unavailability of the electronic MAR and lack of a paper backup. Additionally, a CMA administered an initial dose of a narcotic and performed a pain assessment, both outside her permitted scope of practice. Facility staff and physicians were not promptly notified of these medication errors, which affected residents with complex medical needs.
Multiple residents did not receive their scheduled morning medications, including antihypertensives, psychotropics, and cardiac drugs, until several hours late after a CMA delayed administration due to lack of access to the MAR following an internet outage. The delay affected residents with conditions such as dementia, hypertension, stroke, and heart failure, and facility physicians were not notified of the late administration as required by policy.
The facility did not follow its prepared menus for multiple meals due to ongoing food supply shortages and budget constraints, resulting in frequent meal substitutions and staff purchasing food out of pocket. Staff and dietary management reported insufficient funds to order required menu items, and the dietician was not always informed of or able to approve all substitutions. Despite these issues, there was no significant resident weight loss and residents reported satisfaction with the food.
The facility did not follow its Plan of Correction to ensure consistent RN coverage, failing to utilize a pool of RNs, arrange telehealth services, or review RN staffing in SOC meetings. QAPI meetings were not held as required, and RN coverage was not discussed or addressed, resulting in multiple days without RN oversight.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 34 days over three months. This deficiency was confirmed through staffing data and timecard reports. The CNO acknowledged the policy requirement for daily RN coverage, but the facility did not meet this standard, potentially risking resident care.
The facility failed to prevent infection spread by transporting clean laundry in an uncovered cart through common areas. A housekeeping staff member and the LVN in charge were unaware of the requirement for covering laundry during transport, and the facility lacked a policy for clean laundry delivery.
The facility failed to provide adequate incontinent care for four residents, resulting in skin issues and discomfort. A resident with severe cognitive impairment was found with reddened skin and dried feces, while another with no cognitive impairment had a reddened scrotum and urine odor in his room. A third resident, dependent on total assistance, had dried feces and an open area on her coccyx. A fourth resident experienced burning sensations and stained bed sheets. Staff interviews revealed issues with training and access to care information.
The facility failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for resident care during routine operations and emergencies. The Administrator and DON acknowledged that the available assessment was outdated and inaccurate, with discrepancies in resident census and needs. Despite requests, no policy regarding the assessment was provided, potentially risking resident care.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, as pre-employment screenings for several staff members were incomplete. Observations showed a CNA working without completed paperwork, and interviews revealed misunderstandings about screening responsibilities. The facility's policies were not followed, risking resident safety.
The facility failed to provide required training on abuse, neglect, and exploitation to its staff, including the DON, an LVN, and three CNAs. Personnel files lacked documentation of training for 2023 and 2024, and pre-hire training completions were missing for the CNAs. Interviews revealed awareness of the issue, but no additional documentation was available to demonstrate compliance with training policies.
A resident with severe cognitive impairment experienced mismanagement of personal funds by the facility, resulting in a negative balance. The facility failed to accurately track transactions during a staff transition, leading to overdrawn funds. The administrator acknowledged the issue and the facility's policy on managing funds was not followed.
A resident requiring maximum assistance for transfers was at risk due to a malfunctioning sit-to-stand mechanical lift with a broken wheel lock. Despite staff awareness of the issue, it was not reported, and the maintenance supervisor was unaware until informed by surveyors. The facility's policy mandates equipment readiness, but the lift was not promptly repaired, leading to a deficiency.
A resident with severe cognitive impairment experienced a burn incident after spilling coffee on herself. The facility failed to notify the resident's physician and representative promptly, with delays of several days. The facility's policy requires immediate notification of significant changes in a resident's condition, which was not followed in this case.
A resident with severe cognitive impairment experienced a coffee burn incident, but the LTC facility failed to document the incident and subsequent care accurately and promptly. The DON and an LVN assessed the resident's skin, noting it was pink with no blisters, but did not document these observations until four days later, leading to inaccuracies in the records.
The facility failed to employ a qualified Dietary Supervisor, as the individual did not complete the required dietary manager training course. Interviews and record reviews revealed that the Dietary Supervisor only had a food handler's certificate and not the necessary manager's safe food handling training or certification as a dietary manager.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Various food items in the refrigerator and dry storage were found without proper labeling or sealing, as confirmed by Cook A and the Dietary Supervisor. This was in violation of the facility's food storage policies.
A facility failed to provide appropriate urinary catheter care for a resident with neuromuscular dysfunction of the bladder and prostatic hyperplasia. The facility did not document the catheter type and size, did not irrigate the catheter as ordered, and failed to complete catheter care and output documentation every shift. The resident reported discomfort, and the family expressed concerns about inconsistent catheter care.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, seven days a week, during October and November 2023. Specifically, there was no RN coverage on three specific days. The DON and Administrator, both of whom were not employed during the deficiency period, confirmed the expectation for seven-day-a-week RN coverage.
A resident with diabetes and a pressure ulcer did not receive a carbohydrate-controlled diet with added protein powder as ordered by the physician. The dietary supervisor admitted to not following the specific dietary orders, and the resident was unaware of the need for protein powder in his meals.
The facility failed to ensure that a resident's indwelling urinary catheter bag was covered, compromising the resident's right to a dignified existence. Observations revealed the catheter bag was viewable from the hall, and interviews confirmed that the staff did not adhere to the care plan requiring the bag to be covered.
A facility failed to secure signed consents for the use of a security camera in a resident's room, violating privacy policies. The resident, with moderate cognitive impairment, expressed a desire for privacy and had not agreed to the camera's presence. The DON admitted the oversight, and the facility's policy requirements for electronic monitoring were not met.
The facility failed to provide proper respiratory care for two residents, including not changing oxygen tubing weekly and not properly storing nebulizer masks, potentially placing residents at risk for infections.
The facility failed to administer insulin on time for a resident with Type 2 Diabetes and Diabetic Chronic Kidney Disease. The insulin was administered late on multiple occasions, with delays ranging from over an hour to more than three hours past the scheduled time. This was confirmed through observations and interviews with the nursing staff and the DON.
The facility failed to secure medications on one of two medication carts and in the medication storage room. An LVN left Medication Cart A unlocked inside an unlocked medication room with the door propped open on two separate occasions. The DON confirmed that medications should be locked up anytime a nurse walks away from them, and the facility's policy states that medication carts should never be left open or unattended.
A facility failed to maintain accurate clinical records for a resident, including documentation of catheter care and medication administration. The DON confirmed the absence of required documentation despite staff training.
The facility failed to maintain an effective training program, resulting in several staff members missing critical training in areas such as communication, QAPI, behavioral health, HIV, restraint reduction, and falls. Interviews revealed systemic issues in the training process, with responsibilities divided between HR and department heads, leading to gaps in training compliance.
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff (RNs, LVNs, and CNAs) per shift daily. Observations on multiple dates showed incomplete postings, which was confirmed by the DON and Administrator. The facility's policy requires posting of actual hours worked and census at the start of each shift.
The facility failed to maintain a training program to ensure staff were trained in effective communication. Two staff members, an RN and a CNA, did not receive the required communication training. The HR representative and DON admitted that some staff did not attend the in-service training meetings, and the facility did not adhere to its own policies on mandatory training.
The facility failed to ensure that all staff received training in Quality Assurance and Performance Improvement (QAPI), specifically RN B and CNA D. Record reviews and interviews revealed that the HR and department heads did not adequately ensure training compliance, placing residents at risk of receiving care from untrained staff.
The facility failed to ensure that three staff members received required behavioral health training, as revealed by record reviews and interviews. This failure could place residents at risk of receiving care from untrained staff. The HR and DON admitted to gaps in the training process, indicating a systemic issue in ensuring compliance with training requirements.
Improper Disposal and Overflow of Facility Garbage Dumpsters
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for two outdoor dumpsters located at the back of the property. During an observation, both dumpsters were seen with lids open and unable to close because bagged garbage was stacked above the rim. Additionally, 11 bags of trash and 5 cardboard boxes were observed on the ground outside the dumpsters. The facility did not provide an Environmental Policy when requested by surveyors. In interviews, a CNA reported that staff had to pile trash bags on top of already full dumpsters and sometimes leave trash bags on the ground beside them, and stated that the dumpsters had not been emptied in weeks. The CNA also stated she had voiced concerns to the Administrator but nothing had been done. The Maintenance Director acknowledged responsibility for the trash on the ground and stated the dumpsters were overflowing because sanitation had not collected them due to lack of payment, and that he had not recently hauled trash to the landfill as he sometimes did. Both the Maintenance Director and the Administrator acknowledged that overflowing dumpsters and open lids could attract pests to the facility grounds and possibly into the facility.
Incomplete Documentation of Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for four residents with diabetes who required blood glucose monitoring and insulin administration. Specifically, the Medication Administration Records (MARs) and related documentation for these residents were found to be incomplete, with multiple instances where nurses did not initial or record insulin administration, blood glucose monitoring results, or meal announcements as ordered. These omissions were identified across several dates and affected both residents using insulin pumps and those receiving insulin injections. For example, one resident with type 1 and type 2 diabetes and an insulin pump had missing nurse initials for insulin administration, meal announcements, and blood glucose checks on several occasions. Another resident with similar diagnoses had missing documentation for both insulin and Ozempic administration, as well as for meal announcements and blood sugar checks. Two additional residents with type 2 diabetes, one of whom also had chronic kidney disease, had incomplete records for insulin injections, sliding scale insulin coverage, and fasting blood glucose checks. In several cases, the amount of insulin administered and the corresponding blood sugar levels were not documented as required. Interviews with staff revealed inconsistencies in the documentation process and uncertainty about whether medications and monitoring were performed as ordered. The DON acknowledged that there was no way to confirm if insulin was administered when documentation was missing. Staff interviews also indicated that the responsibility for blood glucose checks and insulin administration sometimes shifted between night and day shift nurses, and that documentation was not always completed in the electronic MAR. The facility's policy required detailed documentation of insulin administration and blood glucose monitoring, but this was not consistently followed for the residents reviewed.
Failure to Maintain Essential Services and Timely Vendor Payments
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, resulting in widespread unpaid debts and disruption of essential services. Key services such as phone and internet were disconnected due to non-payment, forcing staff to use personal cell phones and prepaid devices to conduct facility business and allow residents to communicate with their families. The facility van lacked insurance and current registration, preventing residents from attending medical appointments. Staff members purchased essential supplies such as milk, coffee, laundry soap, bleach, and incontinent briefs out of their own pockets because the facility did not provide adequate funds or pay vendors. Maintenance and laundry services were also compromised, with the hot water heater for laundry out of service for over a month and washing machines lacking proper chemicals and servicing due to unpaid bills. Multiple interviews with staff, including the DON, dietary manager, maintenance director, and housekeeper, confirmed that the facility was unable to purchase necessary supplies or maintain equipment due to outstanding vendor balances. The dietary manager reported substituting menu items because the food budget was insufficient, and staff had to buy food items themselves. The maintenance director and laundry supervisor stated that they could not obtain needed repairs or chemicals for laundry sanitation, and staff had to use cold water and inadequate cleaning agents. The lack of phone and internet service also hindered communication with families, physicians, and pharmacies, impacting the ability to send or receive critical information and documentation. Residents were directly affected by these deficiencies. Several residents missed important medical appointments because the facility van was uninsured and unregistered. One resident's family had to transport her to the ER, and the facility used the uninsured van to pick her up. Residents and their families expressed concerns about communication barriers and missed care opportunities. Staff and department heads repeatedly reported the lack of response from facility leadership regarding supply needs and unpaid bills, and the absence of an administrator further exacerbated the situation. The cumulative effect of these failures resulted in an Immediate Jeopardy situation, as essential care and services required for residents' well-being were not reliably provided.
Removal Plan
- The CEO and Managing Partner re-educated the COO on the governing board responsibility to ensure management and operation of the facility, emphasizing oversight of facility care and services and vendor payments.
- The CEO and COO will review and make payments or payment arrangements for outstanding vendor invoices, including telephone/internet, van insurance, van registration, fire and security vendor, and others. Emergency plans for communication and documentation (hot spots, paper MARs/TARs) will be implemented as needed.
- The DON will complete a Medication Error Form for each of the identified residents with medication errors, including communication with providers, responsible parties, management, and pharmacist consultant, and corrective actions.
- The DON will re-educate nurses and certified medication aides on policies for administering medications and medication errors, using one-on-one meetings and memos, and will conduct Medication Pass Observations.
- The CEO and COO will post the facility administrator's vacant position and continue active recruitment, with a sign-on bonus. Until filled, supply needs will be communicated to the DON and HR Director, with conference calls to ensure vendor payments and resident services.
- Staff will be reimbursed for out-of-pocket expenses per usual procedures, and HR will instruct staff not to purchase items for the facility in the absence of the administrator; all purchases will be made by the administrator and/or HR Director after the conference call.
- Annual van registration and insurance will be added to the annual maintenance checklist, with the administrator reviewing the checklist during QAPI to ensure renewal.
- An ad-hoc QAPI meeting will be held, and the Medical Director will be notified of the deficient practice and removal plan. Action items will be reviewed during QAPI meetings, with meeting minutes maintained.
Failure to Appoint Administrator and Maintain Essential Services
Penalty
Summary
The facility failed to ensure that a governing body appointed a state-licensed administrator responsible for managing the facility, resulting in a prolonged period without an administrator. During this time, the only administrative staff present were the DON and Human Resource Director, who reported that the facility had not been paying vendors, leading to the disconnection of essential services such as telephone, internet, and food deliveries. Staff members were forced to use their personal funds to purchase basic supplies for residents, including food, hygiene products, and laundry supplies, as the facility was unable to maintain regular operations due to unpaid bills. Multiple interviews with staff, including the DON, maintenance director, dietary manager, and others, revealed that the lack of an administrator and insufficient financial support from the governing body resulted in significant operational disruptions. The facility's phone and internet services were disconnected, making communication with families and healthcare providers difficult. The van used for resident transportation lacked insurance and current registration, causing residents to miss important medical appointments. Essential services such as laundry and food preparation were compromised, with staff reporting the use of cold water for laundry due to a broken hot water heater and the need to substitute menu items because of insufficient food supplies. Residents and their representatives expressed concerns about the absence of an administrator and the impact on care, including delays in hospice placement and missed medical appointments. The facility's inability to pay vendors also affected maintenance, with necessary repairs and services being delayed or denied. The cumulative effect of these failures led to the identification of Immediate Jeopardy, as the lack of oversight and resources placed residents at risk of decreased quality of life and care.
Removal Plan
- Re-educate the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility, with emphasis on oversight of facility care and services and vendor payments.
- Meet to review and make payments or payment arrangements for outstanding vendor invoices, including telephone/internet, van insurance, van registration, and fire/security services.
- If the internet is out, staff will use Hot spots for internet access; if Hot spots are not working, the DON will obtain paper-printed MARs and TARs from the pharmacy.
- The Social Worker will call each family to share the mobile phone number if/when needed.
- The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed.
- The Human Resource Director will contact the facility's vendors to share the phone number if/when required.
- Meet to review the facility's outstanding invoices and ensure vendor payments.
- The Director of Nursing (DON) will complete a Medication Error Form for each of the identified residents with medication errors, including communication with providers and corrective actions.
- The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms.
- The DON will re-educate nurses and certified medication aides on policies for administering medications and medication errors, using one-on-one meetings and memos, and will complete Medication Pass Observations.
- Provide education regarding obtaining MARs and TARs from the pharmacy if no internet is available, and Hot spots will be available for use.
- Post the facility administrator's vacant position and continue active recruitment, with a sign-on bonus.
- Communicate all items needed for resident care to the DON and HR Director, who will participate in conference calls with the CEO and COO to ensure vendor payments and supply needs.
- Continue conference calls with the new administrator once onboarded, and review minutes during QAPI to determine supply needs.
- Educate staff to communicate supply needs to HR, who will ensure supply is replenished before items run out.
- Educate laundry staff to notify HR when chemical supply is low.
- The Maintenance Director will monitor supply levels and communicate needs to HR.
- Department heads will monitor supplies and communicate needs to HR.
- Reimburse staff for out-of-pocket expenses per usual procedures, and HR will instruct staff not to purchase items for the facility in the absence of the administrator; all purchases will be made by the administrator and/or HR Director after the conference call.
- Add annual van registration and insurance to the annual maintenance checklist, and the administrator will review the checklist during QAPI.
- Hold an ad-hoc QAPI meeting, and notify the Medical Director of the deficient practice and removal plan; review action items during QAPI, with meeting minutes maintained.
Failure to Maintain Hygienic Laundry Practices Due to Lack of Hot Water and Sanitizing Chemicals
Penalty
Summary
The facility failed to properly handle, store, process, and transport linens in accordance with accepted national standards, resulting in unsanitary laundry conditions. The washing machine used for resident linens did not have hot water due to a broken hot water heater, and the machine itself displayed an error code and required servicing. The facility was unable to obtain necessary repairs or order the required sanitizing chemicals because of unpaid bills to vendors. As a result, staff resorted to purchasing bleach and laundry detergent themselves, which were not the required chemicals for proper sanitization. Multiple staff, including the Maintenance Director, Housekeeper, Laundry Supervisor, and DON, confirmed the lack of hot water, absence of proper chemicals, and inability to service the equipment. The CEO was unaware of the situation until interviewed. Observations revealed that linens stored in the facility were stained, had dark spots, and emitted a musty or urine odor, indicating inadequate cleaning. The laundry supervisor reported that the issue had persisted for over a month, and the problem had been reported to maintenance and corporate, but no resolution had occurred. The facility's census at the time was 23 residents. There were no reports of residents having skin issues or infections related to the laundry at the time of the survey.
Failure to Facilitate Timely Hospice Care per Resident Request
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating timely access to hospice care as requested by the resident. The resident, an elderly female with a history of multiple myeloma in remission and poly osteoarthritis, was cognitively intact and her own responsible party. She began experiencing significant, persistent pain and requested hospice services to help manage her symptoms. The facility physician promptly wrote an order for hospice care and increased pain medication, but the initiation of hospice services was delayed due to facility policy requiring CEO approval before ancillary services could be provided. Despite the resident's ongoing pain and repeated requests for hospice, as well as communication from the DON to the CEO requesting approval, no timely action was taken. The DON provided documentation of her request to the CEO, but did not receive a response. The resident, her POA, and facility staff all confirmed that the delay was due to the need for corporate approval, and the CEO later stated that hospice contracts had to be reviewed on a case-by-case basis. The resident continued to experience high levels of pain during this period, with pain scores consistently between 6 and 8 out of 10, and only partial relief from pain medications. Interviews with facility staff, the resident, and her POA confirmed that the delay in hospice initiation was not due to clinical reasons but rather administrative requirements. The facility's own policies stated that hospice services are available to residents at the end of life and that the DON or designee should contact the hospice agency to determine the resident's wishes. However, these policies were not followed, resulting in an eight-day delay before hospice services were finally initiated for the resident.
Failure to Provide Working Telephone for Resident Communication
Penalty
Summary
The facility failed to provide residents with a working telephone, resulting in a lack of access to communication with family members and representatives. The phone service was terminated after the facility did not pay the phone vendor, and the service was not restored. From the date of disconnection, residents were without access to a facility phone for several days until a staff member purchased a prepaid cell phone with personal funds. Multiple interviews with staff, family members, and the ombudsman confirmed ongoing difficulties in contacting the facility and residents, with reports of unanswered calls and busy signals when attempting to reach the facility number. Family members expressed frustration and concern over their inability to communicate with loved ones, and staff reported receiving personal calls from families seeking updates. Residents also reported being unable to contact their families due to the non-functioning phones. Observations by the investigator confirmed that the facility phone line remained inaccessible, consistently giving a busy signal. Review of the facility's Resident Rights policy indicated that residents are entitled to access to a telephone, which was not provided during this period.
Failure to Provide Timely Medical Appointments and Hospice Services Due to Transportation and Administrative Delays
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for several residents. Specifically, three residents did not attend their scheduled doctor appointments for follow-up and other medical needs due to the facility van being unavailable. The van was not used because its registration had expired and the insurance policy had been canceled, as confirmed by interviews with the Human Resource Director, DON, CNA, and the insurance company. Staff reported that the lack of van insurance prevented them from transporting residents to critical medical appointments, and there was no log of van usage during this period. One resident with multiple chronic conditions, including heart failure, diabetes, and kidney disease, missed nephrology and cardiology appointments that were not rescheduled in a timely manner. Another resident experiencing light vaginal bleeding was unable to be transported to her physician as requested, and although the physician offered to come to the facility, this did not occur. The resident was eventually transferred to the emergency room by ambulance. A third resident missed a primary care appointment for the same reason. Documentation and interviews confirmed that these missed appointments were directly related to the facility's inability to provide transportation due to the lack of van insurance and registration. Additionally, the facility failed to provide hospice services to a resident who requested them for uncontrolled pain, despite a physician's order and the resident's expressed preferences. The process was delayed because corporate approval was required before ancillary services could be initiated, resulting in an eight-day delay before hospice services were arranged. The resident, her POA, and the facility physician all expressed concern about the delay, and documentation showed that the resident continued to experience pain while waiting for hospice care. The facility's policy required communication with and access to services, but this was not followed in these cases.
Delay in Hospice Services and Inadequate Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident with a history of multiple myeloma in remission and poly osteoarthritis, who experienced frequent and significant pain. Despite the resident's request for hospice services due to uncontrolled pain, there was an 8-day delay in arranging hospice care, attributed to the facility's requirement for CEO approval before initiating such services. During this period, the resident continued to report pain levels that were not adequately controlled by the prescribed medications, and her care plan interventions were not fully effective in managing her discomfort. Documentation revealed that the resident's pain was assessed and pain medications were administered, but scheduled doses were missed on at least two occasions without the knowledge of the DON. The facility also failed to consistently document pain monitoring as ordered by the physician, and there was a lack of communication with the physician regarding the resident's breakthrough pain. The resident and her POA both expressed concerns about the delay in hospice services and ongoing pain, while the physician indicated that she expected her orders for hospice and pain management to be carried out promptly due to the critical nature of the situation. Interviews with facility staff and review of facility policy indicated that pain assessments and interventions were not always conducted or documented according to professional standards and the facility's own procedures. The CEO stated that the delay in hospice initiation was due to the need for contract approval, and considered the response time adequate, despite the resident's ongoing pain. The failure to promptly arrange hospice services and to consistently monitor and manage the resident's pain as ordered resulted in a deficiency in providing safe, appropriate pain management consistent with the resident's care plan and preferences.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Record review and interviews confirmed that for 3 of 12 months reviewed, there was no RN coverage for multiple days, specifically 28 out of 47 days. The Human Resource Director and the Director of Nursing (DON) both confirmed that there was no RN coverage during the DON's medical leave and that, even after her return, RN coverage was only provided Monday through Friday. There was no RN present in the facility on weekends, although staff could contact the DON by phone if needed. The CEO also confirmed that the DON works only Monday through Friday and that no one had applied for the RN position to cover weekends. The DON acknowledged that during her absence, there was no RN coverage in the building. A facility policy regarding RN coverage was requested but was not provided by the time of exit. The lack of RN coverage was verified through staffing records and staff interviews.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of all drugs and biologicals to meet the needs of each resident. During a medication pass, twelve residents did not receive their scheduled medications as ordered. Specifically, two residents did not receive any of their 8:00 am medications, and multiple residents received their morning medications more than one hour after the scheduled administration time. The delay was attributed to the unavailability of the electronic Medication Administration Record (MAR) due to an internet outage, and the lack of a paper backup MAR until later in the morning. As a result, all morning medications were administered after 11:00 am on the affected day. Additionally, a Certified Medication Aide (CMA) operated outside her scope of practice by administering an initial dose of a narcotic medication and performing a pain assessment for a resident. According to state regulations and facility policy, CMAs are not permitted to administer the initial dose of a medication that has not been previously given to a resident, nor are they allowed to conduct physical, psychological, or social assessments that require professional nursing judgment. The CMA confirmed in interviews that she administered the first dose of morphine and assessed the resident's pain, actions which were not permitted under her certification. Interviews with facility staff, including the DON and facility physicians, revealed that the physicians were not notified of the late or missed medication administration. The DON was unaware that two residents did not receive their medications at all, and both physicians expressed concern upon learning of the delays and omissions. The facility's own policies and state regulations were not followed, resulting in medication errors including omissions and wrong-time administration for multiple residents with significant medical conditions such as heart failure, hypertension, diabetes, and cognitive impairments.
Significant Medication Administration Delays Due to MAR Unavailability
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically for seven out of eleven residents reviewed. On a specific morning, a Certified Medication Aide (CMA) did not administer scheduled morning medications, including antihypertensives, psychotropics, and cardiac medications, at their prescribed times. Instead, these medications, which were ordered to be given between 7:00 am and 8:00 am, were not administered until after 11:00 am. This delay was confirmed through Medication Administration Record (MAR) reviews and interviews with staff and residents. The affected residents had various diagnoses, including Alzheimer's disease, hypertension, stroke, dementia, anxiety disorder, bipolar disorder, congestive heart failure, schizophrenia, and chronic kidney disease. Many of these residents were severely cognitively impaired, as indicated by low BIMS scores, while others were cognitively intact. Interviews with residents revealed that most were unaware of the late administration or could not recall if their medications were given late. The MARs for each resident confirmed the late administration of multiple critical medications, such as amlodipine, lisinopril, metoprolol, carvedilol, hydralazine, clonidine, depakote, buspirone, quetiapine, and amiodarone. The delay in medication administration was attributed to the unavailability of the electronic MAR and physician orders due to an internet outage. The CMA reported not feeling comfortable administering medications without access to the MAR and waited until a paper copy was provided, which did not occur until after 11:00 am. The Director of Nursing (DON) and facility physicians were not notified of the delay at the time it occurred. The facility's policy on medication errors defines omissions and wrong-time administration as errors and requires prompt physician notification of significant errors, which did not happen in this instance.
Failure to Follow Prepared Menus Due to Food Supply and Budget Issues
Penalty
Summary
The facility failed to follow menus that were prepared in advance for a period covering 11 meals, resulting in multiple substitutions due to insufficient food supplies. Staff interviews revealed that the facility experienced ongoing shortages of essential food items such as milk, bread, coffee, and sweeteners, with staff members and the dietary manager purchasing food out of their own pockets to supplement the supplies. The dietary manager reported that the allocated budget was insufficient to purchase the food required to follow the planned menus, leading to frequent substitutions and menu changes. The dietician was not always aware of or able to approve all substitutions, and the facility did not provide a dietary policy when requested by the investigator. Observations confirmed that food supplies in the pantry and storage areas were low, with only nonperishable items available for seven days and a lack of posted menus in the dining room. Staff interviews indicated that residents were not always informed about what was being served, and that menu substitutions were made based on what could be purchased within the limited budget. The dietary manager provided a detailed substitution log showing numerous instances where planned meals were replaced with alternative items due to cost or availability constraints. Despite these deficiencies, record reviews indicated that there was no significant weight loss among residents during the period in question, and residents reported that the food was good. However, the facility's failure to follow the prepared menus and ensure adequate food supplies was attributed to budgetary limitations and issues with vendor payments, as confirmed by the DON, Human Resource Director, and dietician. The dietician also expressed concerns about the food budget and acknowledged that she was not always informed of all menu changes.
Failure to Implement and Monitor RN Coverage and Quality Assurance Processes
Penalty
Summary
The facility failed to implement and maintain appropriate plans of action to address previously identified quality deficiencies, specifically regarding RN coverage. Despite a Plan of Correction (POC) that outlined the use of a pool of RNs from neighboring or sister communities to ensure at least 8 consecutive hours of RN coverage per day, 7 days a week, the facility did not follow through with these arrangements. Record reviews and interviews revealed that there was no RN coverage on multiple dates, particularly during the DON's medical leave and on weekends, as the DON only worked Monday through Friday. The facility also did not utilize telehealth RN services as previously planned, and staff were reportedly not trained or encouraged to use telehealth options. Additionally, the facility failed to conduct weekly reviews of RN coverage in Standard of Care (SOC) meetings as required by their POC, due to the absence of an Administrator and the discontinuation of regular SOC meetings. The facility also did not discuss these quality deficiencies in monthly QAPI meetings for three months, with only one QAPI meeting held during the period in question and no discussion of RN coverage documented. Job postings for RN positions were not provided, and there was no evidence of active recruitment for RNs. These failures resulted in periods without RN oversight, as confirmed by staffing records and interviews with facility staff.
Failure to Maintain RN Coverage 8 Hours Daily
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, for 34 out of 92 days during the months of October, November, and December 2024. This deficiency was identified through a review of the PBJ Staffing Data Report, which showed no RN coverage on specific dates within this period. The absence of RN coverage was confirmed by the Human Resources department, which provided timecard reports indicating the lack of RN presence on the specified days. The Chief Nursing Officer (CNO) acknowledged the facility's policy requiring an RN to be on staff for 8 hours daily and stated that weekend coverage was available, with the CNO being reachable by phone 24/7 if needed. However, the facility's failure to maintain consistent RN coverage could potentially place residents at risk, as decisions requiring an RN's expertise in managing healthcare needs and monitoring direct care staff might not be made. The policy statement provided by the facility reiterated the requirement for RN services to be available for at least eight consecutive hours every day of the week.
Failure to Properly Transport Clean Laundry
Penalty
Summary
The facility failed to handle, store, process, and transport linens in a manner that prevents the spread of infection. During an observation, a housekeeping staff member was seen delivering clean laundry using an uncovered cart. The staff member transported the laundry to various rooms, moving the uncovered cart through common areas such as the lobby and dining room. Upon interview, the housekeeping staff member stated she was unaware that a cover was required for the cart during transport. Additionally, the Licensed Vocational Nurse (LVN) in charge at the time of the survey was also unaware of the requirement for covering clean laundry during transport and confirmed that the facility did not have a policy in place for the delivery of clean laundry. This lack of proper procedure and awareness could potentially place residents at risk for healthcare-associated cross-contamination and infections.
Inadequate Incontinent Care Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide necessary bowel and bladder incontinent care for four residents, resulting in skin issues and discomfort. Resident #2, a female with severe cognitive impairment and chronic kidney disease, was observed with reddened skin and dried feces on her buttocks. Her care plan required prompt assistance, but no skin assessments were completed during the review period. Resident #3, a male with no cognitive impairment but requiring maximum assistance for ADLs, was found with a reddened scrotum and a strong urine odor in his room. His care plan included regular checks for incontinence, but similar to Resident #2, no skin assessments were documented. Resident #4, a female dependent on total assistance, was observed with dried feces and an open area on her coccyx, indicating a lack of proper incontinent care. Resident #7, a male with moderate cognitive impairment, experienced burning sensations and had dark red skin in the groin area. Observations revealed stained bed sheets and inadequate care. Interviews with staff highlighted issues with training and access to care information, as a new CNA was not properly set up to access resident care plans. The facility's failure to adhere to its policy on resident rights and dignity was evident, as no specific policy on maintaining hygiene was provided by the administration.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified during interviews and record reviews, revealing that the facility had not updated its assessment to reflect current resident needs and census. The Administrator admitted that the only available assessment was outdated and inaccurate, and it was found in the emergency preparedness book. Additionally, the Director of Nursing (DON) was unaware of who was responsible for maintaining the assessment and confirmed that it was not up to date with the current resident census. The facility's emergency preparedness book contained outdated acuity levels for evacuation purposes, with discrepancies in the total resident census and specific resident needs. The document titled Facility Assessment, found by the Administrator, was also outdated and lacked accuracy. Despite multiple requests for the facility's policy regarding the assessment, the Administrator was unable to provide any additional documentation or policy. This lack of a current and accurate facility-wide assessment could potentially place residents at risk of not receiving the necessary care and services required.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified in the files of four employees, including three CNAs and one LVN, where pre-employment screenings such as criminal background checks, EMR, and NAR checks were not completed before their employment dates. The absence of these checks could place residents at risk for abuse, neglect, and exploitation. Observations revealed that one CNA was in possession of blank new hire paperwork on her first day of work, and she was instructed to work the floor before completing her paperwork. Interviews with the ADM indicated a lack of awareness regarding the incomplete pre-employment screenings and a misunderstanding of the requirements for completing these checks before allowing staff to provide care. The ADM believed that the responsibility for these checks lay with the Human Resources department, which was shared between three facilities. The facility's policies on abuse prevention and employee screening were not adhered to, as evidenced by the lack of documentation in the employee files. The ADM and Human Resources acknowledged the deficiencies in the files and the ongoing efforts to rectify them, but at the time of the survey, the necessary pre-employment checks had not been completed for the employees in question.
Lack of Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to provide necessary training to its staff on critical areas such as abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during interviews and record reviews, which revealed that the Director of Nursing (DON), a Licensed Vocational Nurse (LVN A), and three Certified Nursing Assistants (CNA E, CNA F, and CNA G) had not received the required training for 2023 or 2024. The personnel files lacked documentation of pre-hire training completions for the CNAs, and the DON and LVN A had no records of training for the past two years. Interviews with the Administrator (ADM) and Human Resources indicated awareness of the missing training documentation and acknowledged the disorganized state of the files. The facility's policies, including the Abuse Prevention Program, mandate that all new employees receive in-service training on abuse prohibition before working a shift, and current employees must receive annual training. However, the facility did not adhere to these policies, as evidenced by the lack of training records. The ADM confirmed that there was no additional documentation available to demonstrate compliance with the training requirements. This oversight could potentially impact resident care and increase the risk of abuse due to insufficient staff training.
Mismanagement of Resident's Personal Funds
Penalty
Summary
The facility failed to properly manage the personal funds of a resident, leading to a negative balance in the resident's trust account. The resident, who has severe cognitive impairment and is her own responsible party, was found to have a negative balance of $369.63 in her trust account. This occurred after a series of transactions, including a credit from Social Security and debits for room and board and cash disbursements, which were not accurately tracked by the facility. The facility's administrator admitted to not having answers regarding the resident's trust funds and acknowledged that the facility was not keeping accurate records during a transition of staff. The administrator explained that the business office manager (BOM) position was shared among three facilities, which contributed to the mismanagement of funds. The facility had taken out more money than the resident had in her account, leading to the negative balance. The administrator also mentioned that the facility gave the resident additional money despite knowing her account was overdrawn. The facility's policy on managing residents' personal funds states that they should act as a fiduciary and inform residents in advance of any charges, which was not adhered to in this case.
Inadequate Supervision and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who required maximum assistance with transfers using a mechanical lift. The resident, a male with a history of type 2 diabetes, chronic kidney disease, cerebral infarction, and muscle weakness, was observed using a sit-to-stand mechanical lift with a broken wheel lock. This malfunction was noted during an observation where the lift moved during a transfer, despite staff attempts to steady it. Interviews with staff revealed that they were aware of the broken lock but had not reported it, and the maintenance supervisor was also unaware of the issue until informed by the surveyors. The facility's policy requires equipment to be ready for use at all times, but the broken lift was not addressed promptly, posing a risk to residents. The maintenance supervisor later contacted the company responsible for inspections to fix the lift, but there was no expected arrival date for the necessary part. The facility's failure to maintain the mechanical lift in proper working condition and ensure staff awareness and reporting of equipment issues led to the deficiency.
Failure to Notify Physician and Representative of Resident's Burn Incident
Penalty
Summary
The facility failed to promptly notify a resident's physician and representative of a significant change in the resident's condition following a burn incident. The incident occurred when the resident spilled coffee on herself, resulting in burns to her lower extremities. Despite the incident occurring on May 10, 2024, the physician was not notified until May 13, 2024, and the resident's representative was informed on May 14, 2024. This delay in communication was contrary to the facility's policy, which mandates immediate notification of the physician and representative in the event of a significant change in a resident's condition. The resident involved was an elderly female with a history of lung cancer, Alzheimer's Disease, and cognitive deficits. Her cognitive impairment was severe, as indicated by a BIMS score of 03. The facility's records showed that the resident's skin was initially intact and pink with no blisters, but by May 13, 2024, the skin on her thighs was peeling. The facility's policy requires that any significant change in a resident's condition, which impacts their health status and requires intervention, should be promptly communicated to the physician and the resident's representative. The failure to adhere to this policy could result in care issues, as acknowledged by the Director of Nursing during an interview.
Failure to Document Resident Incident and Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced a coffee burn incident. The resident, a female with severe cognitive impairment due to Alzheimer's Disease and other conditions, spilled coffee on herself, resulting in burns on her lower extremities. Despite the incident occurring on May 10, 2024, there were no nursing notes, incident notes, or progress notes documented until May 14, 2024. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) assessed the resident's skin on the day of the incident, noting it was pink with no blisters, and changed her clothes. However, this assessment and subsequent observations were not documented until four days later, leading to inaccuracies in the records. The DON admitted to failing to document the immediate treatment provided, such as applying cool rags, and acknowledged that the documentation entered later was incorrect. The facility's policy requires documentation of resident care upon admission and as needed, but this was not adhered to in this case. The lack of timely and accurate documentation could result in improper documentation, as noted by the DON. The facility's failure to document the incident and the resident's condition accurately and promptly was a significant deficiency in maintaining clinical records according to professional standards.
Failure to Employ Qualified Dietary Supervisor
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. Specifically, the Dietary Supervisor did not complete an approved dietary manager training course. This deficiency was identified through interviews and record reviews, which revealed that the Dietary Supervisor only had a food handler's certificate and not a manager's safe food handling training. Additionally, there was no documented evidence that the Dietary Supervisor had completed a certified dietary manager course, despite being employed in this position since February 2023 and starting the dietary manager course in July 2023. Interviews with the Business Office Manager (BOM) and the Dietary Supervisor confirmed that the necessary training and certifications had not been completed. The Dietary Supervisor's job description required her to be a graduate of an accredited course in diabetic training approved by the American Diabetic Association and to be registered as a Food Service Director in the state. The facility's Professional Staffing policy also stipulated that a qualified director of food and nutrition services must be a certified dietary manager or a certified food service manager. The U.S. Food and Drug Administration's 2022 Food Code further specified that the person in charge must be a certified food protection manager who has shown proficiency through passing a test that is part of an accredited program.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the facility kitchen, it was found that various food items in the refrigerator were not labeled with an open date or identifier. Items such as Sweet N Sour sauce, a gallon jar of an unknown substance, a bag with a sliced lemon, a bottle of ketchup, a bag with sliced sandwich turkey, ground hamburger meat, containers of donuts, and apple fritters were all found without proper labeling. Cook A confirmed that any opened food item needed to be labeled with an identifier and date, which was not done in these instances. In the dry storage area, similar issues were observed. Items such as a bag of brown sugar, a bag of small marshmallows, a 50-pound bag of rice, a loaf of bread, and a bag of dinner rolls were found without open dates or proper sealing. The Dietary Supervisor confirmed that the expectation was for all food to be labeled and dated upon opening and stored in sealed containers. The facility's policies for food storage, both for dry goods and cold foods, were reviewed and indicated that all foods should be properly sealed, labeled, and dated, which was not adhered to in these instances.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services. Specifically, the facility did not document the urinary catheter type and size in the physician's order for a resident with neuromuscular dysfunction of the bladder and prostatic hyperplasia. Additionally, the facility did not irrigate the resident's urinary catheter as ordered and failed to complete urinary catheter care and output documentation every shift as required by the physician's orders. The resident, who had a moderate cognitive impairment, reported discomfort and pressure from the catheter, which was not being flushed or cleaned regularly. The resident's family member also expressed concerns about the catheter care not being performed consistently and attempted to discuss these issues with the facility's administrator. The resident's attending physician's assistant confirmed that the catheter size ordered was incorrect and that the catheter care instructions were not being followed accurately. The Director of Nursing acknowledged that the orders were not documented correctly and that the catheter care, irrigation, size, and output should have been completed and documented accurately. The facility's policy on bowel and bladder continence management was not adhered to, leading to potential risks for the resident, including urinary tract infections and catheter-related trauma.
Failure to Provide RN Coverage 7 Days a Week
Penalty
Summary
The facility failed to ensure the use of the services of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week for two of the three months reviewed (October and November 2023). Specifically, there was no RN coverage on October 1, October 15, and November 19, 2023. The Director of Nurses (DON), who started on November 8, 2023, confirmed that she was not employed by the facility in October 2023 and stated that her expectation was for the facility to have seven-day-a-week RN coverage. The Administrator, who was also not employed during the deficiency period, echoed this expectation. The lack of RN coverage on the specified dates could place residents at risk of not having their healthcare needs managed properly.
Failure to Follow Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure that a resident received a carbohydrate-controlled diet with added protein powder as ordered by the physician. The resident, a male with type 2 diabetes mellitus, chronic kidney disease, and an unstageable pressure ulcer, was observed eating a meal that did not comply with his dietary restrictions. The resident was unaware of the need for protein powder in his meals and reported never having received it. The dietary supervisor admitted to not using protein powder in the resident's food and stated that for carbohydrate-controlled diets, she would simply remove the bread, which is not in accordance with the physician's orders. Interviews with the Director of Nursing (DON), the Administrator, the registered dietician, and the resident's physician all confirmed that the expectation was for physician-ordered diets to be followed precisely. The failure to adhere to these dietary orders was acknowledged as a liability and a potential cause for poor clinical outcomes, such as delayed wound healing and increased blood sugar levels. The facility's policy on therapeutic diets mandates that all diet orders be prepared according to the guidelines in the approved diet manual and the individualized plan of care, which was not followed in this case.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident #16's indwelling urinary catheter bag was covered, compromising the resident's right to a dignified existence, self-determination, and communication. Observations revealed that the catheter bag was hanging from the resident's chair without a privacy bag, and it was viewable from the hall due to the open door. The resident expressed a desire for the bag to be covered but did not want to make a fuss about it. Despite having a privacy bag available, it was not used, and the staff failed to adhere to the care plan that required the catheter bag to be covered. Interviews with the LVN and the DON confirmed that the catheter bag should have been covered according to the care plan. The LVN was unsure why the bag was not covered, and the DON acknowledged that the failure to cover the catheter bag could place residents at risk for dignity issues. The facility's policy and procedures on dignity and catheter bag covers were requested but not provided at the time of the survey exit.
Failure to Secure Consent for Security Camera Use
Penalty
Summary
The facility failed to ensure personal privacy by not securing signed consents for the use of security cameras for a resident. Specifically, a security camera was operational in a resident's room without obtaining consent from the resident who occupied the room. The resident, who had moderate cognitive impairment and was independent in her activities of daily living, expressed her desire for privacy and stated that the camera was from a previous occupant. The camera was not pointed at her bed but towards the other side of the room, which was unoccupied. There was no sign indicating that the room was being electronically monitored, and the resident had not agreed to the camera's presence. The Director of Nursing (DON) revealed that the camera was initially placed for a previous resident and had not been removed. The DON admitted that the facility did not realize the current resident had not consented to the camera's presence. The facility's policy required a completed request form for authorized electronic monitoring, consent from any roommates, and a conspicuous notice at the room's entrance. None of these requirements were met in this case, leading to a violation of the resident's privacy rights.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that respiratory care for two residents was provided in accordance with professional standards and the residents' care plans. For Resident #5, who has chronic combined systolic and diastolic heart failure and chronic pulmonary disease, the facility did not change the oxygen tubing weekly as required. Observations revealed that the oxygen tubing was dated 3/18/2024, and the humidifier bottle was not dated, despite the resident receiving oxygen therapy. The resident was unable to recall when the tubing was last changed, indicating a lapse in the facility's adherence to the care plan and infection control protocols. For Resident #30, who has obstructive pulmonary disease and severe cognitive impairment, the facility failed to properly store the nebulizer mask and date the tubing. The nebulizer mask was observed on the nightstand without being stored in a bag, and the tubing was not dated. The resident was unable to provide information about the mask, and the Director of Nursing confirmed that nebulizer masks should be stored in plastic bags when not in use to prevent cross-contamination and infection. These deficiencies highlight the facility's failure to follow its own policies and procedures for respiratory care, potentially placing residents at risk for infections and communicable diseases.
Failure to Administer Insulin on Time
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin for Resident #14. The resident, a 76-year-old female with Type 2 Diabetes and Diabetic Chronic Kidney Disease, had specific physician orders for insulin administration at 7:00 AM. However, the insulin was administered late on multiple occasions in April 2024, with delays ranging from over an hour to more than three hours past the scheduled time. This failure was observed and confirmed through interviews with the nursing staff and the Director of Nursing (DON), who acknowledged that nurses often got behind on medication passes due to assisting other staff members, leading to the late administration of insulin. On April 29, 2024, it was observed that LVN B was running behind on the medication pass and had not administered the insulin to Resident #14 at the scheduled time of 7:00 AM. The insulin was eventually administered at 8:44 AM, well past the ordered time. The DON confirmed that the expectation was for medications, including insulin, to be administered as per physician orders and acknowledged that the staff had been trained on the importance of timely medication administration. The facility's policy on medication administration emphasized the importance of administering medications at the right time, dose, and route, but this was not adhered to in the case of Resident #14.
Failure to Secure Medication Cart and Room
Penalty
Summary
The facility failed to ensure medications were secured on one of two medication carts and in the medication storage room. During an observation and interview, a Licensed Vocational Nurse (LVN) left Medication Cart A unlocked inside an unlocked medication room with the door propped open. The LVN admitted that this was accidental and acknowledged that it could allow residents to access the medications. This incident was observed on two separate occasions, with the LVN stating that she thought the medication room door was closed and that she was responsible for the medications in the cart. The Director of Nursing (DON) confirmed that the expectation is for medications to be locked up anytime a nurse walks away from them and that staff are trained on these expectations. The Administrator was observed putting up a new sign on the medication room door to remind staff that the door should be closed and locked at all times when unattended. The facility's policy and procedure on Medication Administration, dated January 2013, clearly states that medication carts should never be left open or unattended. Despite this policy, the failure to secure the medication cart and room was observed, indicating a lapse in adherence to established protocols. This deficiency could potentially allow residents to gain access to medications, posing a risk of drug diversion.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and current clinical records for a resident, specifically in relation to catheter care and medication administration. The resident, a male with multiple diagnoses including congestive heart failure, neuromuscular dysfunction of the bladder, hypertension, and prostatic hyperplasia, had an indwelling catheter. The facility's records indicated that the catheter was changed as per the order, but there was no corresponding nursing note documenting this change as required by the facility's policy. Additionally, the facility did not maintain accurate medication records for the resident. There were multiple instances where medications were not documented as given, refused, or held. The medications in question included treatments for hypertension, constipation, neuromuscular dysfunction of the bladder, chronic idiopathic constipation, reflux, dry eyes, major depressive disorder, intestinal obstruction, hypothyroidism, moderate pain, and anemia. The lack of documentation spanned several dates and times, and the nursing notes did not reflect any reasons for the missed documentation, such as the resident being absent from the facility. In an interview, the DON confirmed the absence of documentation for the catheter change and the medication administration. She acknowledged that all nursing staff had been trained on documentation and following orders, and she was responsible for ensuring that documentation was entered. The facility's policy on documentation was reviewed, but a copy of the policy covering documentation and medication administration was not provided at the time of the exit interview.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective general training program for its staff, resulting in several deficiencies. Specifically, the facility did not ensure that RN B, LVN C, CNA D, and CNA E received necessary training in areas such as communication, QAPI, behavioral health, HIV, restraint reduction, and falls. Personnel files revealed that these staff members were missing critical training components, which are essential for providing competent care to residents. The HR department was responsible for orientation training, while department heads were tasked with ensuring ongoing training. However, this division of responsibilities led to gaps in training compliance, as evidenced by the missing training records for the staff members reviewed. Interviews with the HR and DON highlighted systemic issues in the training process. The HR indicated that while she conducted monthly in-service training sessions, it was up to the department heads to ensure their staff received the necessary training. The DON admitted that some staff members did not attend the in-service meetings and were too busy to review the training materials later. This lack of follow-through and accountability resulted in staff members not being adequately trained, as required by the facility's policies and handbook. The facility's failure to ensure comprehensive training for all staff could place residents at risk of receiving care from untrained or incompetent staff members.
Failure to Post Actual Nursing Hours Worked
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff (RNs, LVNs, and CNAs) directly responsible for resident care per shift daily. Observations on multiple dates revealed that the daily nursing staffing information was posted but did not include the total numbers of actual hours worked for each direct care staffing type. This omission was confirmed by the Director of Nursing (DON), who acknowledged that the form was incomplete and did not meet the facility's policy requirements. In an interview, the Administrator confirmed that the policy was not followed, as the total numbers of actual hours worked for RNs, LVNs, and CNAs, as well as the census at the beginning of each shift, were missing from the posting. The facility's policy, revised in September 2014 and reviewed in November 2019, mandates that facility census and nursing staff information be posted on each shift, including the actual number of hours of direct care provided. The failure to comply with this policy could affect residents and visitors who may want to know the staffing levels and actual hours worked per shift daily.
Failure to Maintain Effective Communication Training for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in effective communication. Specifically, two staff members, RN B and CNA E, did not receive the required communication training. RN B was hired on 08/22/2022, and CNA E was rehired on 12/15/2023. The HR representative stated that while she was responsible for orientation training, each department head was responsible for subsequent trainings. The Director of Nursing (DON) admitted that some staff did not attend the in-service training meetings and that she would inform them to read the material and sign the sheets later, which often did not happen due to their busy schedules. The facility's policy on training compliance and the employee handbook both emphasize the importance of attending orientation and mandatory in-service training sessions. However, the record review revealed that the facility did not adhere to these policies, as evidenced by the lack of communication training for RN B and CNA E. This failure to ensure all direct care staff were trained on communication could place residents at risk of receiving care from untrained staff.
Failure to Ensure Staff Training in QAPI
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in Quality Assurance and Performance Improvement (QAPI) for two staff members, RN B and CNA D. Record reviews revealed that RN B, hired on 08/22/2022, and CNA D, hired on 03/15/2024, did not receive the required QAPI training. Interviews with the HR representative and the Director of Nursing (DON) indicated that while the HR was responsible for orientation training, department heads were responsible for subsequent trainings. The HR representative mentioned that in-service training sheets were signed by attendees, but it was the responsibility of each department head to ensure their staff received the trainings. The DON admitted that some staff did not attend the meetings and were too busy to complete the training materials later, leading to gaps in training compliance. The facility's policy on training compliance and the employee handbook both emphasized the importance of mandatory training and attendance at designated meetings. However, the failure to ensure that all staff, including RN B and CNA D, received QAPI training placed residents at risk of receiving care from untrained or incompetent staff. The deficiency was identified through record reviews and interviews, highlighting a lapse in the facility's training program and oversight by department heads.
Failure to Ensure Behavioral Health Training for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in behavioral health, affecting three out of ten reviewed staff members (RN B, CNA D, CNA E). Record reviews revealed that these staff members did not receive the required behavioral health training. RN B was hired on 08/22/2022, CNA D was hired on 03/15/2024, and CNA E was rehired on 12/15/2023. This lack of training could place residents at risk of receiving care from incompetent or untrained staff. The facility's policy mandates that all newly hired employees attend orientation within the first five days of employment and participate in compliance training within 30 days of employment, which was not adhered to in these cases. Interviews with the HR representative and the Director of Nursing (DON) revealed gaps in the training process. The HR representative stated that while she was responsible for orientation training, each department head was responsible for ensuring their staff received ongoing training. The DON admitted that some staff did not attend the in-service training meetings and were too busy to review the training materials later. This indicates a failure in the facility's system to ensure that all staff members receive the necessary behavioral health training, as required by their policies and federal law.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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