Greenville Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Texas.
- Location
- 3500 Park St, Greenville, Texas 75401
- CMS Provider Number
- 675367
- Inspections on file
- 30
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Greenville Gardens during CMS and state inspections, most recent first.
The facility did not maintain a detailed record of receipt or perform periodic reconciliation for controlled medications awaiting destruction. Controlled drugs were stored in a locked cabinet, but the process relied on verification at the time of receipt and destruction, without ongoing documentation or reconciliation as required by policy. This resulted in incomplete records and a lack of accountability for controlled substances.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not maintain an effective pest control program, resulting in persistent gnats and flying insects in the memory care unit. Multiple residents were observed swatting at gnats, and staff confirmed the ongoing presence of pests despite the use of traps and chemicals. The issue was acknowledged by both the Maintenance Director and the Administrator, and pest control treatment was only documented after the problem was observed by surveyors.
A resident's bathroom light was observed flashing rapidly for several days, causing discomfort. The malfunction was not reported in the maintenance log as required, and the Maintenance Director was unaware of the issue until he noticed it himself. Facility policy requires a safe, comfortable, and homelike environment, including proper lighting, but this was not maintained.
A resident with severe cognitive impairment and multiple mental health diagnoses was prescribed Clonazepam for anxiety, but the facility failed to include this medication in the resident's care plan. Despite staff discussions of resident changes in daily meetings, the care plan was not updated to reflect the new medication, contrary to facility policy.
A resident with a suprapubic catheter was found to have an unsecured Foley catheter, despite care plans and facility policy requiring securement with a leg strap. Nursing staff and the DON confirmed that catheters should be checked and secured every shift, but were unable to account for the lapse during the survey.
A resident did not receive enough food and fluids to maintain their health, as identified by surveyors through observations and records showing unmet nutritional and hydration needs.
Drugs and biologicals were not labeled according to accepted professional principles, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with intact cognition and specific food dislikes repeatedly received meals containing tomato products and green peas, despite these preferences being documented and communicated to dietary staff. The resident reported feeling ignored, and both the Dietary Manager and Administrator acknowledged that such preferences should be honored, as confirmed by facility policy.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
A resident with a history of aggressive behavior attacked two other residents, causing physical harm and emotional distress. Despite having a care plan to manage his behavior, the facility failed to prevent these incidents, resulting in a deficiency in care standards.
The facility failed to implement its abuse prevention policy when a resident with schizoaffective disorder and dementia physically assaulted two other residents. Despite the incidents being witnessed and reported to the doctor and family, the facility did not report them to the appropriate authorities, citing the aggressor's dementia as a reason for non-willful actions. This failure to report placed residents at risk of unreported abuse and decreased quality of life.
The facility failed to report incidents of resident-to-resident abuse within the required timeframe. A resident with schizoaffective disorder and dementia physically assaulted two other residents, causing one to fall and be sent to the ER. Despite being witnessed by staff, these incidents were not reported to HHSC, as required by the facility's policy. The DON believed the actions were not willful due to the resident's dementia diagnosis, leading to non-compliance with abuse reporting requirements.
A resident with schizoaffective disorder and dementia was sent to a behavioral hospital due to aggressive behavior. Despite stabilization, the facility did not allow the resident to return, citing safety concerns. The decision was made by corporate, and the family was not informed until they inquired. The facility failed to provide necessary documentation and communication as per their discharge policy.
The facility failed to ensure residents on the secured unit met the criteria for placement, as several residents were placed there despite assessments indicating no or moderate elopement risk. Documentation and assessments were inconsistent with residents' needs, and staff interviews revealed a lack of clarity regarding the necessity of secured unit placement.
A facility failed to monitor the effects of psychotropic medications for three residents, leading to inadequate behavior and side effect documentation. Despite pharmacy recommendations, the facility did not implement necessary monitoring for residents on medications like Venlafaxine, Lexapro, and Duloxetine, affecting their therapeutic outcomes.
A facility failed to monitor smoking materials and dispose of razors properly, creating safety hazards. A resident was found with cigarettes on his bedside table, against policy, while another resident with dementia had a razor on a window ledge. Staff interviews revealed lapses in policy enforcement, posing risks of fire and injury.
A facility reported a medication error rate of 5.17%, involving two residents. One resident did not receive MiraLAX as ordered, while another received incorrect dosages of fluticasone and guaifenesin. The errors were attributed to a medication aide's haste and improper documentation. Interviews with facility leadership confirmed expectations for accurate medication administration and documentation.
The facility failed to secure medications properly, leaving a resident's medication at the bedside and an unlocked medication cart unattended. A medication aide was distracted, leaving a resident's wound healing medication unsecured, while an LVN left an insulin pen on an unlocked cart. These actions violated facility policies and could risk resident safety.
The facility failed to maintain professional food service safety standards, as three muffin tins with carbon build-up, rust, and food particles were used in the kitchen. The Dietary staff and Manager acknowledged the potential for food contamination, and the Administrator confirmed that such equipment should not be used due to the risk of causing stomach issues for residents.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene between glove changes during insulin administration to a resident with multiple health conditions, including diabetes. This lapse was acknowledged by the LVN and confirmed as an infection control issue by the ADON and DON, highlighting a breach in the facility's hand hygiene policy.
A resident with multiple health conditions, including dementia and schizophrenia, was found to have a non-functional call light in their room, which could have delayed assistance. The issue was confirmed by staff and later fixed by the Maintenance Director. The facility's policy required immediate reporting and replacement of defective call lights, but this was not adhered to, resulting in the deficiency.
The facility failed to maintain an effective pest control program, leading to the presence of gnats in two resident rooms. A female resident with cognitive impairment and a male resident with a pelvic fracture both experienced issues with gnats. Despite regular cleaning, the housekeeper was not instructed to perform additional checks, and the pest control technician was unaware of the gnat problem in the rooms. Staff interviews revealed a lack of communication and reporting, highlighting the need for better coordination to maintain a clean environment.
A male resident with a history of mobility issues and falls was found smoking on a public roadway, highlighting gaps in supervision. Despite needing assistance with transfers and having a care plan for safe smoking practices, the resident smoked outside designated areas without proper oversight. Facility staff, including the DON and Administrator, were unaware of his location until informed by surveyors. The resident's revoked smoking privileges and lack of effective communication and monitoring contributed to the deficiency.
A resident did not receive their scheduled medications timely, leading to a significant delay in administration. The medication aide called in sick for her first shift, and the nursing staff on duty did not administer the medications, resulting in the resident receiving them several hours late.
Failure to Maintain Accurate Receipt and Reconciliation of Controlled Drugs Awaiting Disposal
Penalty
Summary
The facility failed to establish and maintain a detailed system for the receipt and reconciliation of all controlled drugs, specifically for medications awaiting disposal. During an observation, several controlled medications, including Hydrocodone/APAP, Alprazolam, Diazepam, and Lorazepam, were found stored in a locked cabinet awaiting destruction. The Director of Nursing (DON) reported that when controlled medications were brought to her, she verified the count with a nurse and both signed the narcotic sheet before placing the medication in the locked box. However, the DON did not reconcile these medications prior to their destruction with the pharmacy consultant, and there was no record of receipt for controlled medications awaiting disposition to allow for accurate and periodic reconciliation. Record review showed that the last medication destruction was completed several weeks prior, and the facility's policy required two licensed nurses to document and witness the removal of discontinued or expired narcotics from active inventory, with proper storage and a signed destruction log. Despite these policies, the process described by the DON and Administrator did not include logging the receipt of controlled medications awaiting destruction, and reconciliation was only performed at the time of destruction. This lack of documentation and periodic reconciliation could result in incomplete records and an inability to accurately account for all controlled substances in the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Pest Control in Memory Care Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in the memory care unit, resulting in the presence of gnats and other flying insects. Multiple observations documented gnats in residents' rooms, including in a water cup at a bedside and flying around residents as they ate or watched TV. Staff interviews confirmed that gnats were a persistent issue, with one CNA stating that traps were set but gnats were always present, and that the insects were bothersome to residents. The Maintenance Director acknowledged awareness of the problem and described the use of wall-mounted bug lights and drain chemicals, but admitted that gnats could be a health risk and that the issue persisted. The Administrator stated that the facility should be reasonably pest free for resident comfort and recognized the unsanitary conditions created by gnats in water cups or on food. Review of the pest control log indicated that treatment for gnats in the memory care unit only occurred after survey observations began. The facility's pest control policy required ongoing efforts to keep the building free of pests, with staff responsible for reporting signs of infestation. However, the observations and interviews demonstrated that the pest control measures in place were insufficient to prevent or eliminate the presence of gnats in the memory care unit.
Failure to Maintain Safe and Comfortable Resident Environment Due to Malfunctioning Bathroom Light
Penalty
Summary
A deficiency was identified when a resident's bathroom light was observed to be flashing rapidly over multiple days. The resident expressed that the flashing light was bothersome, although he could not specify how long it had been occurring. The issue was not reported in the facility's maintenance log, and the Maintenance Director confirmed that he was unaware of the malfunction until he noticed the flashing lights himself. Staff are required to report such issues in the maintenance logbook, but this was not done in this instance. Further review of the facility's policy indicated that the environment should be safe, clean, comfortable, and homelike, with lighting that is comfortable and suitable for residents' needs. The Administrator acknowledged that a flashing light could create an uncomfortable environment and stated that it is the Maintenance Director's responsibility to ensure lighting issues are addressed. The failure to report and promptly address the malfunctioning bathroom light resulted in the resident experiencing a non-homelike and uncomfortable environment.
Failure to Develop Comprehensive Care Plan for Antianxiety Medication
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address all of a resident's identified needs, specifically omitting a care plan for the administration of Clonazepam, an antianxiety medication. The resident in question was an elderly female with diagnoses including anxiety, depression, and dementia, and had a severely impaired cognitive status as indicated by a BIMS score of 03. She required maximum assistance with activities of daily living and was receiving Clonazepam both in the morning and at bedtime for anxiety, as documented in her physician orders. However, a review of her comprehensive care plan did not show any mention of Clonazepam or related interventions. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new medication orders. Although staff reported discussing resident changes during daily morning meetings, the care plan for this resident was not updated to reflect the use of Clonazepam. The facility's own policy required care plans to be revised as needed based on changes in resident condition, but this was not followed in this instance.
Failure to Secure Foley Catheter for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when a male resident with a history of benign prostatic hyperplasia and obstructive uropathy, who required a suprapubic catheter, was observed to have his Foley catheter unsecured during a survey. The resident was dependent on staff for toileting and had an order in place for staff to check the securement of his catheter every shift. During the survey, both the Assistant Directors of Nursing (ADONs) and the charge nurse were unable to explain why the catheter was not secured, and the catheter strap was not found in the resident's clothing. The facility's care plan and policy required the catheter to be anchored with a leg strap to prevent trauma and infection, but this was not followed at the time of observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that catheters were supposed to be checked and secured every shift, and that failure to do so could result in trauma or infection. The DON and Administrator both stated that monitoring catheter securement was their responsibility, but neither had noticed issues prior to the survey. The facility's policy specifically outlined the need to anchor catheters to prevent complications, yet this protocol was not adhered to for this resident.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to accommodate a resident's documented food preferences and dislikes, specifically regarding tomato products and green peas. Despite the resident's dietary card indicating these dislikes, the resident received meals containing these items on multiple occasions, including buttered peas, mixed vegetables with green peas, and spaghetti with tomato meat sauce. The resident, who had intact cognition and was independent with eating, reported to staff that she did not like these foods, yet continued to receive them. The resident expressed that her preferences were not being considered, and photographic evidence was provided to support her claims. Interviews with the Dietary Manager confirmed awareness of the resident's dislikes and an expectation that alternatives should be provided when these items were on the menu. However, the Dietary Manager was not aware of the most recent incident and stated that the cook was responsible for ensuring appropriate substitutions. The Administrator also confirmed that food preferences and dislikes were expected to be followed, with oversight by the Dietary Manager through spot checks. Review of facility policy indicated a requirement to accommodate individual resident needs and preferences.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to physical harm and emotional distress. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior towards other residents. On two separate occasions, Resident #1 physically attacked Resident #2 and Resident #3. Resident #2, a female with severe cognitive impairment, was pulled by the hair by Resident #1, causing her to fall and require an emergency room evaluation for a hand contusion. Resident #3, a male with similar cognitive impairments, was hit on the chest by Resident #1, although he did not sustain any injuries. The facility's records indicate that Resident #1 had a history of aggressive behavior, as noted in his care plan, which included interventions to protect others. Despite this, the facility did not effectively prevent Resident #1 from harming other residents. The incidents were witnessed by staff, and the facility's policy on violence between residents required such altercations to be promptly reported and addressed. However, the facility's response was inadequate, as evidenced by the repeated incidents involving Resident #1. Interviews with staff and the Director of Nursing (DON) revealed that the incidents were reported to the doctor and family members, but there was a lack of consensus on whether Resident #1's actions constituted abuse due to his dementia diagnosis. The facility's policy on abuse prevention emphasizes zero tolerance for abuse and the protection of residents from harm by others, including fellow residents. The failure to adhere to these policies and adequately protect residents from abuse resulted in a deficiency in the facility's care standards.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, as evidenced by incidents involving two residents. The facility's policy, titled 'Abuse Prevention and Prohibition Program,' mandates that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but no later than two hours after forming the suspicion. However, the facility did not adhere to this policy when Resident #1 pulled Resident #2's hair, causing her to fall and be sent to the ER for evaluation, and when Resident #1 hit Resident #3 on the chest. These incidents were not reported to the state survey agency, adult protective services, law enforcement, or the Ombudsman as required. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior, including running down the hallway with fists up, being combative, and attacking staff and residents. His care plan included interventions to protect the rights and safety of others, such as approaching him calmly and removing him from situations as needed. Despite these measures, Resident #1 was involved in two separate incidents where he physically assaulted other residents. The facility's failure to report these incidents as abuse, as per their policy, placed residents at risk of unreported abuse and a decreased quality of life. Resident #2, a female with severe cognitive impairment, was standing in the hallway when Resident #1 pulled her hair, causing her to fall. She was sent to the ER for evaluation, where she was diagnosed with a hand contusion. Resident #3, a male with severe cognitive impairment, was sitting in the dining room when Resident #1 hit him on the chest. Both incidents were witnessed by staff, and the doctor and family were notified, but the facility did not report them to the appropriate authorities, citing that Resident #1's actions were not willful due to his dementia diagnosis. This decision was contrary to the facility's policy, which requires reporting all incidents of abuse, regardless of the perpetrator's intent.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframe for two residents. Specifically, the facility did not report to the Health and Human Services Commission (HHSC) when one resident pulled another resident's hair, causing her to fall and be sent to the emergency room for evaluation. Additionally, the facility did not report when the same resident hit another resident on the chest. These incidents were not reported immediately, as required, which could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior, including verbal outbursts and physical aggression towards staff and other residents. His care plan included interventions to protect the rights and safety of others, such as speaking to him calmly and removing him from situations as needed. Despite these measures, Resident #1 was involved in two incidents where he physically assaulted other residents. The facility's records indicate that these incidents were witnessed by staff, and the doctor, family, and Director of Nursing (DON) were notified, but the incidents were not reported to HHSC. The Director of Nursing stated that the incidents were not reported to HHSC because they were witnessed and because Resident #1 had a diagnosis of dementia, which they believed meant his actions could not be considered willful. The facility's policy on abuse prevention and prohibition requires that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or other incidents be reported immediately, but this was not adhered to in these cases. The failure to report these incidents as required by the facility's policy and regulatory guidelines constitutes a deficiency in the facility's compliance with abuse reporting requirements.
Improper Discharge and Failure to Readmit Resident
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident, who had been admitted with diagnoses including schizoaffective disorder and dementia, was sent to a behavioral hospital for treatment due to aggressive behaviors. Despite the discharge being anticipated as temporary with a return expected, the facility did not allow the resident to return after stabilization and completion of treatment at the behavioral hospital. This decision was made by the facility's corporate office, citing the resident's aggressive behavior as the reason for not readmitting him. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge and potential return. The social worker indicated that the resident was supposed to return to the facility, but the decision not to allow his return was made by the administration and corporate office. The Director of Nursing (DON) mentioned that the facility reviews residents' records before readmission to ensure their needs can be met, but there was no attempt from the behavioral hospital to send the resident back. The resident's family was under the impression that he would return to the facility, and they were not informed of any changes to this plan until they inquired about his return. The facility's policy on transfer and discharge requires documentation and a physician's written statement if a resident is discharged due to endangering the safety or health of others. However, there was no evidence provided that such documentation was completed. The facility also failed to communicate effectively with the resident's family regarding the discharge process and the decision not to allow the resident's return, leading to confusion and distress for the family, who were unable to care for the resident long-term.
Inappropriate Placement of Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that residents on the secured unit met the criteria for residing there, as evidenced by the lack of access codes or information for independent egress for five residents. Specifically, the facility did not appropriately assess the elopement risk for these residents, leading to their unnecessary placement in a secured environment. For instance, Resident #35 was placed on the secured unit despite an elopement risk assessment indicating no risk, and similar issues were noted for Residents #23, #38, #18, and #47, who were either not at risk or only at moderate risk of elopement. The report highlights that the facility's documentation and assessments were inconsistent with the residents' actual needs and behaviors. For example, Resident #35's care plan and medication records did not reflect any behaviors indicative of elopement risk, yet she was placed on the secured unit. Similarly, Resident #23, who had severe cognitive impairment and required substantial assistance, showed no documented elopement attempts or wandering behaviors, yet was also placed on the secured unit without proper justification. Interviews with staff, including the DON and CNA, revealed a lack of clarity and documentation regarding the residents' need to be on the secured unit. The DON admitted to being unsure why certain residents remained on the secured unit despite their elopement risk scores indicating otherwise. The facility's policy allowed for administrative discretion in keeping residents on the secured unit, but this discretion was not supported by adequate documentation or assessment, leading to inappropriate placements.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #54, a cognitively intact male with depression, anxiety, insomnia, and high blood pressure, was prescribed Venlafaxine. However, there was no behavior monitoring documented for May and June 2024, despite a medication dose change and pharmacy recommendations to add behavior monitoring. Resident #64, a male with depressive disorders, anxiety, and dementia, had a BIMS score indicating moderately impaired cognition and required total assistance for all ADLs. He was prescribed Lexapro, but there was no behavior or side effect monitoring documented for May and June 2024. The pharmacy had recommended adding behavior monitoring, but the facility did not implement this. Resident #3, a female with depression, dementia, and diabetes, had severely impaired cognition and required total assistance for all ADLs. She was prescribed Duloxetine, but there was no behavior monitoring documented for May and June 2024. Despite pharmacy recommendations to add behavior monitoring, the facility failed to do so. Interviews with facility staff revealed that there was a lack of proper procedures to ensure behavior and side effect monitoring for residents on psychotropic medications.
Inadequate Monitoring of Smoking Materials and Razor Disposal
Penalty
Summary
The facility failed to ensure adequate monitoring of smoking materials for a resident, leading to a potential fire hazard. The resident, who was cognitively intact and required minimal supervision while smoking, was observed with cigarettes on his bedside table, contrary to the facility's policy that smoking materials should be kept at the nurses' station. Interviews with staff revealed a lack of awareness and enforcement of this policy, with the resident admitting to keeping his cigarettes and lighter due to the inconvenience of retrieving them from the nurses' station. Additionally, the facility did not properly manage the disposal of a personal razor for another resident, who had severe cognitive impairment due to dementia. The resident was observed with a disposable razor on the window ledge next to his recliner, which posed a safety risk as other residents who wandered could potentially access it. Staff interviews indicated that razors should be disposed of in a sharps container immediately after use, but this procedure was not followed, leading to a potential injury hazard. The facility's policies on smoking and sharps disposal were not adhered to, resulting in unsafe conditions for residents. The staff, including the DON and Administrator, acknowledged the lapses in policy enforcement and the associated risks, highlighting a need for improved supervision and adherence to safety protocols to prevent accidents and hazards.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with a reported rate of 5.17 percent. This deficiency involved two residents, one of whom did not receive MiraLAX as ordered. The resident, who had a history of type 2 diabetes, peripheral vascular disease, atrial fibrillation, and hypertension, was observed not receiving the prescribed MiraLAX on a specific date. The medication aide responsible for administering the medication admitted to marking the medication as given, despite the resident's refusal, due to being in a hurry. Another resident, with diagnoses including dysphagia, dementia, essential hypertension, and chronic kidney disease, did not receive the correct dosage of fluticasone and guaifenesin as ordered. The medication aide administered only one spray of fluticasone instead of two and failed to provide the guaifenesin tablet due to its unavailability. The aide acknowledged the error and the lack of proper documentation, attributing it to being rushed and nervous during the medication pass. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed the expectation that medications should be administered as ordered. They emphasized the importance of documenting refusals and unavailability of medications accurately. The facility's policy on medication administration was reviewed, highlighting the requirement for licensed nurses to know specific details about the medications they administer and to document any deviations appropriately.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, and that only authorized personnel had access to the keys. This deficiency was observed in one of the three nurse medication carts and involved two residents. Specifically, Resident #69 had his prescribed medication, Prostat AWC oral liquid, left at his bedside, which was against the facility's policy. The medication aide responsible for administering the medication was distracted and did not ensure that Resident #69 took his medication, leaving it unattended at the bedside. Additionally, LVN D failed to secure the 400-hall nurse medication cart when it was left unattended. During the administration of insulin to Resident #43, LVN D left the medication cart unlocked and placed the insulin pen on top of the cart while she went to wash her hands. This action left the medications unsecured and accessible to anyone passing by, which was against the facility's policy that required medication carts to be locked when not attended by authorized personnel. The facility's policies clearly stated that medications should not be left at the bedside and that medication carts should be locked when unattended. The Director of Nursing and the Administrator both acknowledged the failures and emphasized the importance of securing medications to prevent unauthorized access. These lapses in protocol could potentially place residents at risk of injury or medication errors.
Deficiency in Kitchen Equipment Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, three muffin tins were found to have carbon build-up, rust, and food particles, which were not cleaned properly. The Dietary staff acknowledged using these muffin tins and admitted they were not clean, which could potentially lead to food contamination and illness among residents. The Dietary Manager initially believed that the carbon build-up and rust would not affect the food since they were on the outside of the tins. However, upon demonstration that the build-up could be peeled off and food particles were present inside the tins, he conceded that this could lead to bacterial contamination and illness. The Administrator confirmed that such equipment should not be used as it could cause stomach issues for residents. The facility's policy on equipment operation and sanitation requires thorough washing and sanitizing between uses, which was not followed in this instance.
Infection Control Lapse During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D during the administration of insulin to Resident #43. During the procedure, LVN D did not perform hand hygiene after removing gloves and before donning a new pair, which is a critical step in preventing cross-contamination and the spread of infections. This lapse in protocol occurred despite LVN D's acknowledgment of the importance of hand hygiene and her responsibility to ensure it was performed correctly. Resident #43, a male with a history of type 2 diabetes mellitus, metabolic encephalopathy, cerebral infarction, chronic kidney disease, and atrial fibrillation, was receiving insulin as part of his care plan. The failure to perform hand hygiene was observed during a medication administration session, and both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that this was an infection control issue. The facility's policy on hand hygiene clearly states that it is the primary means to prevent the spread of infections and must be performed after removing gloves.
Failure to Maintain Functional Call System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, identified as Resident #69, which could have placed the resident at risk of not receiving timely assistance. On the date of the observation, the resident, who had a history of partial traumatic amputation, dementia, schizophrenia, diabetes mellitus, and weakness, was found to have a non-functional call light in his room. The resident, who required maximal assistance with daily activities such as toileting and transfers, reported having to wait a long time for assistance due to the malfunctioning call light. This was confirmed by both the surveyor and the MDS Nurse, who found that the call light did not activate when pressed. The Maintenance Director and the Administrator verified the malfunction and subsequently fixed the call light. The Maintenance Director stated that he was unaware of the issue until notified by the MDS Nurse and acknowledged that the malfunction should have been detected during morning rounds. The Director of Nursing (DON) expressed that the MDS Nurse was responsible for checking the call lights during rounds and should have reported any malfunctions. The facility's policy required that defective call lights be reported immediately and replaced, but this procedure was not followed, leading to the deficiency.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in two resident rooms. Resident #8, a female with atrial fibrillation, depression, and dementia, was observed with several gnats around her room on multiple occasions. Despite her cognitive impairment, she was aware of the gnats but did not understand their presence. The room was noted to have an odor, and the resident had a history of hoarding, which may have contributed to the issue. The housekeeper reported cleaning the room regularly but was not instructed to perform additional checks for cleanliness. Resident #234, a male with a pelvic fracture, depression, and high blood pressure, also experienced issues with gnats in his room. He reported the problem after becoming frustrated with the persistent presence of gnats. The pest control technician had sprayed common areas, the dining room, and the kitchen for flies and roaches but was not informed about the gnats in the resident rooms. The Maintenance Supervisor and other staff were unaware of the gnat issue until it was brought to their attention. Interviews with various staff members, including the DON, ADON, and the Administrator, revealed a lack of communication and reporting regarding the pest issue. The facility's pest control policy aimed to ensure a pest-free environment, but the oversight and reporting mechanisms were insufficient to address the gnat problem in the resident rooms. The deficiency highlighted the need for better coordination and communication among staff to maintain a clean and sanitary environment for residents.
Inadequate Supervision Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident #1, a [AGE] year-old male with a history of difficulty walking, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and a history of falls. Despite being assessed as needing supervision or touching assistance with various activities, including sit to stand transfers and toilet transfers, Resident #1 was found sitting on a public roadway between parked cars while smoking. This lack of supervision put Resident #1 at risk of injury or harm, considering his medical conditions and the potential dangers of sitting in a space used by cars to parallel park. The facility's care plan for Resident #1 included goals for safe smoking practices, such as smoking in designated areas without injury. However, Resident #1 was observed smoking outside the facility without proper supervision or adherence to the designated smoking areas. Despite receiving warnings and notices for non-compliance with smoking rules, Resident #1 continued to smoke outside the facility, leading to the deficiency in supervision. The facility's policies regarding smoking by residents outlined clear consequences for non-compliance, including loss of smoking privileges, yet Resident #1's actions were not effectively managed to ensure his safety. Observations and interviews revealed gaps in communication and monitoring within the facility regarding Resident #1's whereabouts and activities. Staff members, including the Director of Nursing and Administrator, were unaware of Resident #1's location until prompted by surveyors. Resident #1 himself mentioned leaving the facility to smoke across the street due to his smoking privileges being revoked. The lack of proper documentation, supervision, and communication among staff members contributed to the deficiency in ensuring Resident #1's safety while engaging in smoking activities outside the designated areas.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who did not receive their medications timely as scheduled. On 3/10/2024, the resident's morning medications, including oxycodone, Lasix, Gabapentin, and Aldactone, were administered several hours late. The resident reported that his morning medications were given after lunch, and the Medication Administration Audit Report confirmed the late administration times. The resident's comprehensive care plan required timely administration of medications to manage conditions such as liver disease, high blood pressure, anxiety, and neuralgia, but these requirements were not met on the specified date. The issue arose because the medication aide (MA R) who was scheduled to administer the medications called in sick for her first shift on 3/10/2024. When she arrived for her second shift, she found that the medications had not been administered by the nursing staff on duty. The weekend RN was aware that MA R had called off her first shift but assumed that the nurse on duty had administered the medications. This assumption led to a significant delay in medication administration, which could have resulted in adverse reactions for the resident. Interviews with the weekend RN, the Director of Nursing (DON), the Medical Director, and the Administrator revealed that there was an expectation for medications to be administered timely and according to the physician's orders. The DON and the Medical Director emphasized the importance of administering medications at the correct times to ensure their effectiveness. The facility's Medication-Administration policy also stated that medications should be administered within one hour before or after the scheduled time, which was not adhered to in this case.
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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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