Guadalupe Valley Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seguin, Texas.
- Location
- 1210 Eastwood Dr, Seguin, Texas 78155
- CMS Provider Number
- 455869
- Inspections on file
- 43
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Guadalupe Valley Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, dysphagia, malnutrition, and major depressive disorder had documented behavior of attempting to eat non-food items such as pennies and curtain hooks, as reported by a family member in a nurse practitioner's note. However, the resident's care plan did not include this behavior or related interventions, despite facility policy requiring care plan revisions upon status changes. CNAs knew of the behavior from verbal reports and increased their monitoring but were unsure if it was reflected in the care plan, and the DON was not aware of the issue. This resulted in a deficient practice in developing and implementing a comprehensive, person-centered care plan that addressed all identified needs.
A resident with dementia, Parkinson’s disease, colostomy status, and major depressive disorder, who required substantial assistance with bathing, did not have a documented provider order in the EMR for an enema that an LVN reported receiving verbally from an NP, although a related MiraLAX order was entered. In addition, the resident’s bathing record initially showed only a few showers, but later updates revealed previously undocumented entries for a bed bath, a refusal of bathing, and a day when bathing was not applicable, despite CNAs stating they regularly provided and were trained to document bathing care. These issues occurred despite facility policies requiring complete, accurate, and timely documentation of ADLs and clinical services in the medical record.
Surveyors found that the facility did not consistently remove discontinued or expired controlled medications from medication carts, failed to reconcile and document controlled substance counts, and did not always follow required procedures for wasting medications. Multiple residents with complex medical needs were affected, and staff interviews revealed inconsistent adherence to facility policies regarding controlled substance management.
A nurse administered five medications to a resident more than two hours before the scheduled time, resulting in a medication error rate of 45%. The medications included Gabapentin, Cyclobenzaprine, Colace, Carboxymethylcellulose Sodium ophthalmic gel, and Rosuvastatin. The nurse did not follow physician orders or facility policy regarding medication timing, and the resident was unaware of the medications received or their timing.
A resident with dementia was found to have lorazepam stored in a refrigerator with only a partially illegible label on the box and no resident or prescription information on the medication bottle itself. Staff relied on the box label to identify the medication, and interviews revealed confusion between the facility and pharmacy regarding relabeling procedures. Facility policy indicated the pharmacy was responsible for labeling all medications.
A resident with multiple complex medical conditions, including a Stage 2 pressure ulcer, did not have wound care dressing changes consistently documented on the TAR as required. Despite active orders and a care plan for skin integrity, several wound care treatments were not recorded, and sections of the wound evaluation forms were left incomplete. Nursing staff interviews confirmed that missing documentation typically indicated the treatment was not performed, and staff could not account for the omissions.
A resident with multiple complex medical conditions developed a Stage 2 pressure ulcer, but the facility failed to notify the physician or document any notification as required. The Wound Care Nurse did not record communication with the physician, and interviews with staff confirmed that the expected notifications were not made or documented, despite facility policy requiring such action for clinical complications.
A resident with complex medical needs, including metastatic cancer and impaired mobility, developed a Stage 2 pressure wound. The facility did not update the care plan to include measurable objectives or interventions for wound care and resident refusals, and staff interviews revealed unclear responsibility for care plan revisions. The care plan failed to address the resident's changing condition and did not guide staff on managing refusals or new wounds.
A resident with multiple medical and mental health diagnoses was found to have three disposable razors left in his room without proper care planning or staff awareness. Staff interviews revealed uncertainty about facility policy regarding razor storage, and the resident's care plan did not address razor use or storage. The DON and Administrator confirmed that permissions for residents to keep razors should be documented but were not, and the facility lacked a policy on this issue.
A nurse failed to notify the appropriate clinical staff after identifying a Stage 2 pressure ulcer in a resident with complex medical needs. Required notifications to the physician and interdisciplinary team were not documented, and the nurse was unclear about wound staging protocols and notification requirements. This deficiency resulted in a lack of timely intervention and oversight for the resident's pressure injury.
A nurse failed to follow infection control protocols by placing a Gabapentin capsule on a piece of paper atop the medication cart and handling it with bare hands before administering it to a resident with multiple medical conditions. This action was not in line with facility policy, which requires medications to be handled in a manner that prevents contamination.
CNAs failed to fully close a broken privacy curtain while providing incontinent care to a resident with Alzheimer's disease and other chronic conditions, resulting in exposure of the resident's genital area in the presence of a roommate. Both CNAs confirmed the lapse in privacy and noted they had received resident rights training, but were unaware of the curtain's condition as they did not usually work in that area.
A CNA did not change gloves or perform hand hygiene after cleaning a resident's buttocks and before handling clean linens and briefs during incontinent care. The resident had multiple chronic conditions and required extensive assistance. The CNA acknowledged the lapse, and the DON confirmed that proper glove and hand hygiene protocols were not followed as required by facility policy.
The facility failed to maintain a sanitary and comfortable environment, as observed in the 300-hall shower room and several resident rooms. The shower room was found with dirty linens, personal care items, and feces stains, while resident rooms were cluttered with food crumbs, used briefs, and personal items. Interviews revealed that cleaning tasks were not consistently performed, leading to dissatisfaction among residents and acknowledgment from staff of the unsanitary conditions.
The facility failed to ensure a safe environment by leaving a razor and an oxygen cylinder unsecured in a shower room, and sharp objects like razors and scissors in resident rooms. Staff acknowledged these items as safety hazards, with CNA J and LVN F admitting to lapses in securing these items. ADON I confirmed the risks associated with these hazards, emphasizing the need for proper disposal and storage of sharp objects.
The facility failed to maintain proper infection control practices, with observations of overflowing dirty linen barrels, soiled towels with feces in a shower room, and blood spots in resident rooms. Staff acknowledged the issues but cited time constraints and lack of awareness. The DON and ADON expressed concerns about cross-contamination risks.
The facility failed to maintain an effective training program for staff, affecting 8 out of 29 employees. Key trainings such as resident rights, communication, and infection control were not provided annually. Interviews revealed a lack of clarity and responsibility among HR and department heads, with no policy in place to ensure compliance. Staff were unaware of training requirements, and the facility did not provide a policy on annual training requirements.
The facility failed to provide mandatory communication training to a cook and two CNAs, as required annually. Personnel records showed no evidence of such training, and interviews revealed a lack of clarity and responsibility among staff regarding training completion. The HR Director noted the importance of these trainings, but the absence of a formal policy and structured process led to this deficiency.
The facility failed to provide mandatory training on resident rights for four employees, including a Food Service Manager and CNAs, as revealed by personnel records and interviews. Despite the importance of these trainings for quality care, there was no evidence of annual training completion, and staff interviews highlighted a lack of clarity and responsibility in ensuring compliance.
The facility failed to provide mandatory QAPI training to a cook and three CNAs, among other essential trainings, as part of its annual requirements. Personnel records showed no evidence of these trainings, and interviews revealed a lack of clarity and responsibility among staff regarding training completion. The absence of a policy and clear accountability could lead to staff being inadequately trained, potentially affecting resident care.
The facility failed to provide mandatory annual infection control training for a cook, CNA B, and CNA D, as revealed by personnel records. Interviews with the HR Director, food service manager, and DON highlighted a lack of clarity and responsibility for ensuring training completion, with no policy in place to ensure compliance.
The facility failed to provide mandatory behavioral health training for a Cook, a Maintenance Assistant, and a CNA, as required by the facility's assessment. Personnel records showed no evidence of annual training completion, and interviews revealed a lack of clarity and responsibility among staff regarding training oversight. The HR Director admitted there was no policy to ensure training completion, potentially affecting resident care.
A resident with spastic hemiplegic cerebral palsy and moderate cognitive impairment was found to have their call light inaccessible, tucked in a drawer, preventing them from calling for help. The resident was dependent on staff for daily activities, and the care plan required the call light to be within reach to prevent falls. Staff interviews confirmed awareness of the resident's difficulty using the call light, and the facility's policy emphasized accessibility, which was not followed in this instance.
A facility failed to discuss Medicaid coverage and healthcare provider options with a newly admitted resident, who had minimal cognitive impairment and required medical attention for conditions like hemiplegia and diabetes. The resident expressed concerns about not being informed about insurance changes and healthcare needs, and the BOM and SW had not conducted a transitional meeting due to missing documents for Medicaid application.
A resident with Type 2 Diabetes Mellitus did not receive their prescribed insulin, Toujeo, due to an insurance denial and subsequent pharmacy delivery failure. The nursing staff did not notify the resident's physician or nurse practitioner, contrary to orders. The resident reported elevated glucose levels and expressed frustration over the recurring issue. Interviews revealed a lack of communication and adherence to protocol, as the night nurse failed to reorder the medication or use an alternative insulin available in the emergency kit.
A resident with Type 2 Diabetes Mellitus did not receive a scheduled dose of Toujeo insulin due to the facility's failure to ensure its availability. The night nurse did not notify the NP or document the incident, and the alternative insulin in the emergency kit was not administered. The issue was resolved the following day after the resident expressed his concerns.
The facility failed to provide mandatory annual training on abuse, neglect, and other critical areas for a cook and a CNA, potentially affecting resident care. Personnel records showed no evidence of required training completion, and interviews revealed a lack of clarity and responsibility among staff regarding training enforcement.
The facility failed to provide mandatory ethics training for a cook, as well as other required annual trainings, potentially affecting resident care. Personnel records showed no evidence of completed trainings, and interviews with staff revealed a lack of policy and oversight in ensuring training compliance. The HR Director, Food Service Manager, and DON acknowledged the importance of these trainings, but the facility lacked a structured approach to ensure they were completed.
The facility failed to provide mandatory annual dementia training for a CNA, as revealed by personnel records and interviews with the HR Director, DON, and ADM. Despite the availability of trainings through Health Stream, there was no policy to ensure completion, leading to a deficiency in staff training.
A facility failed to provide appropriate respiratory care for a resident requiring continuous oxygen therapy. During a transfer, a CNA, who had not received training on oxygen use, handled the resident's nasal cannula and oxygen tubing. Interviews revealed a lack of clarity and training regarding oxygen equipment handling by CNAs, and the facility lacked a policy on this matter.
A facility failed to ensure proper medication storage and administration, as observed with a resident who had medications left on their nightstand and floor. The resident, with cognitive impairment and chronic pain, was unable to identify the medication. An MA had administered the medication but was unaware the resident might have pocketed it. Additionally, a pill was found on the floor in a hallway, and an LPN left a medication cart unlocked and unattended, posing a security risk. The DON acknowledged the importance of securing medications to prevent unauthorized access.
A resident's privacy was compromised during catheter care when two CNAs left the door open and did not fully draw the privacy curtain. The resident, with multiple medical conditions, felt undignified by the lack of privacy. Staff interviews confirmed the expectation to maintain privacy, highlighting a lapse in following established procedures.
A resident with an indwelling catheter did not receive proper catheter care, as staff failed to hold the catheter at the insertion site during cleaning, risking trauma and infection. Interviews confirmed the correct procedure was not followed, and the facility lacked a clear catheter care policy.
The facility failed to ensure nurse aides demonstrated competency in essential care skills, as observed in two instances. One resident received improper perineal care from a CNA who reused a wipe surface and omitted cleaning necessary areas. Another resident with an indwelling catheter received incorrect catheter care, risking infection and trauma. Interviews revealed training inconsistencies, with CNAs trained by peers and no designated nurse for training. Despite documentation of competency, observed deficiencies indicate a gap in training and adherence to procedures.
A facility failed to maintain accurate medical records when a MA documented an incorrect heart rate for a resident with multiple health conditions. The error was not corrected in the EMR due to the MA's inability to make changes and failure to report it to a nurse. The resident, despite the error, reported no symptoms of low heart rate.
Two residents received improper care due to infection control deficiencies. A CNA failed to follow proper perineal care procedures, risking cross-contamination by not removing wipes from the package beforehand and reusing the same surface of a wipe. Another CNA did not adhere to catheter care protocols, holding the catheter incorrectly and risking infection. Staff interviews confirmed a lack of adherence to established procedures, despite training.
A resident with a history of Alzheimer's and other health issues exhibited symptoms of a stroke, including facial drooping and slurred speech. Despite these significant changes, the facility staff failed to promptly notify the resident's physician and responsible party. The delay in communication and assessment led to the identification of an Immediate Jeopardy situation, as the resident's condition required timely medical intervention.
A resident with a history of Alzheimer's and other health issues exhibited symptoms of a possible stroke, including facial drooping and slurred speech. Despite these signs, the CNA's report to the LVN was not acted upon promptly, and the physician was not notified until the following day. This delay in care led to an Immediate Jeopardy situation, as the resident's condition was not assessed or treated in a timely manner.
Failure to Update Care Plan for Resident Eating Non-Food Items
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and time frames to meet a resident's identified needs. The resident was an elderly female with dementia, need for assistance with personal care, mild protein calorie malnutrition, dysphagia, and major depressive disorder. A quarterly MDS showed moderate cognitive impairment with a BIMS score of 8/15. A Comprehensive Encounter note dated 02/17/2026, authored by a nurse practitioner, documented that a family member reported the resident had been trying to eat non-food items such as pennies and curtain hooks. Despite this documented behavior, review of the resident's undated care plan showed no mention of attempts to eat non-food items. Certified nursing assistants reported in interviews that they were aware the resident would eat non-food items and that they needed to keep a closer watch on her, but they learned this information from other staff and were unsure if it was included in the care plan. They stated they typically relied on the care plan and verbal shift reports to know how to care for residents. The DON stated in an interview that he had not been made aware that the resident was trying to eat non-food items. The administrator acknowledged that the resident's attempts to eat non-food objects could be added to the care plan. Observation of the resident showed confusion and inability to respond appropriately to interview questions, with no observed attempts to eat non-food items at that time. The facility's policy on Care Plan Revisions Upon Status Change required that the comprehensive care plan be reviewed and revised as necessary when a resident experiences a status change, but the care plan had not been updated to address the resident's behavior of attempting to eat non-food items.
Incomplete and Inaccurate Medical Record Documentation for Enema Order and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely medical records for a resident with dementia, Parkinson’s disease, colostomy status, major depressive disorder, and a need for assistance with personal care. The resident’s quarterly MDS showed moderate cognitive impairment and a need for substantial/maximal assistance with bathing. On one date, an LVN documented in a nurse’s note that a new order was received for a one-time enema and daily MiraLAX for constipation. The electronic medical record and discontinued orders, however, only contained the MiraLAX order and did not include any physician or NP order for the enema. During interview, the LVN stated she had received a verbal order from the NP to give the enema, could not recall if she entered the order into the electronic record, and acknowledged the importance of having the enema order documented in the record to show when it was given and whether it was effective. The facility also failed to maintain complete bathing documentation for the same resident. Initial review of the resident’s bathing record showed showers on four specific dates only. A later review of the updated bathing documentation showed additional entries indicating a bed bath on another date, a refusal of bathing on a separate date, and a notation that bathing was not applicable on yet another date, all originally missing from the record. CNAs reported they regularly provided showers and were trained to document baths and showers in the electronic medical record. The DON confirmed that the resident’s showers had not been updated in the medical record and that the bathing documentation should have been current. Facility policies required that ADL care, including bathing, be documented at the time of service or by the end of the shift, and that each resident’s medical record contain complete, accurate, and timely documentation of assessments, observations, and services provided.
Failure to Properly Manage and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper management and reconciliation of controlled substances for multiple residents and medication carts. Surveyors observed that discontinued and expired medications were not consistently removed from medication carts on several occasions. Additionally, there were repeated failures to reconcile the administration and count of controlled substances, with numerous instances where counts were not completed or signed for as required. These lapses were identified through observation, interviews, and record reviews involving several residents with complex medical histories, including dementia, pain management needs, and anxiety disorders. Specific findings included the presence of expired or discontinued medications in medication carts, such as Lorazepam and Tramadol, which were not removed after the prescribed period or after discontinuation. In some cases, controlled substances were not administered as documented, and discrepancies were noted between medication administration records and controlled substance logs. Staff interviews revealed inconsistent practices regarding the counting and documentation of controlled substances, with some staff admitting to not counting at the beginning of shifts or failing to sign count records. There were also instances where medications were wasted without the required signatures or without two licensed staff present, contrary to facility policy. Review of facility policies confirmed that controlled substances should be counted at every shift change, with both incoming and outgoing staff signing the records, and that expired or discontinued medications should be promptly removed from carts. However, interviews with nursing and administrative staff indicated a lack of consistent adherence to these policies, with some staff unaware of the requirements or admitting to lapses in practice. The facility's documentation showed numerous missing signatures on controlled drug count records across multiple medication carts and shifts, further evidencing the breakdown in controlled substance management.
Medication Error Rate Exceeds Regulatory Limit Due to Early Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as required by regulation. During observation, interview, and record review, it was found that a nurse administered five medications to a resident more than two hours before the scheduled time, resulting in a medication error rate of 45% (5 errors out of 11 opportunities). The medications involved included Gabapentin, Cyclobenzaprine, Colace, Carboxymethylcellulose Sodium ophthalmic gel, and Rosuvastatin. The nurse admitted to administering the medications early and stated that some residents preferred their medications at specific times, but did not verify the correct timing or dosage as per the physician's orders and facility policy. The resident involved had multiple diagnoses, including dry eye syndrome, constipation, hemiparesis, hemiplegia, and hyperlipidemia. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. The nurse did not follow this policy, and the resident was unaware of the medications received or the timing of administration. Facility leadership confirmed that medications should not be administered more than two hours before the scheduled time, as this could affect medication efficacy.
Failure to Properly Label Resident Medication
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles for one resident reviewed for medication labeling. Specifically, a resident with dementia had a prescription for lorazepam oral concentrate, which was observed stored in the refrigerator inside a plastic baggie. The box containing the medication had a partially illegible label, and the medication bottle itself only had a manufacturer label without any resident or prescription information. Staff indicated they identified the medication by the name on the box, but the bottle itself was not properly labeled. Interviews with facility staff and the pharmacy revealed that the pharmacy required the medication to be returned in order to provide a replacement label, but the facility was unable to send the medication back as it would leave the resident without their medication. The DON stated that the pharmacy could not send replacement labels, and the pharmacist mentioned that the facility could handwrite labels if necessary. Review of facility policy confirmed that the pharmacy was responsible for labeling all dispensed medications.
Failure to Accurately Document Wound Care in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for medical records. Specifically, there were multiple instances where wound care dressing changes were not documented on the Treatment Administration Record (TAR) for a resident with significant medical conditions, including sepsis, metastatic cancer, heart failure, severe malnutrition, and a Stage 2 pressure ulcer. The missing documentation occurred on several specific dates, despite active orders for wound care and interventions outlined in the resident's care plan. Record reviews showed that the resident required regular application of zinc-based cream to the buttock area for skin integrity issues and had a care plan addressing risks related to incontinence and impaired mobility. However, the TAR lacked documentation for wound care on multiple shifts, and skin and wound evaluation forms were incomplete, with sections for practitioner and interdisciplinary notifications left blank. Interviews with nursing staff, including the Wound Care Nurse, LVNs, and RN, confirmed that missing documentation on the TAR typically meant the treatment was not performed, and staff could not account for the omissions. Facility policy required that all assessments, observations, and services provided be documented accurately and timely in the resident's medical record. Staff interviews further revealed that when the Wound Care Nurse was not present, floor nurses were responsible for wound care, but documentation lapses still occurred. The Director of Nursing acknowledged that missing documentation would appear as if care was not provided, and that the facility's process included reviewing records for such lapses, yet the deficiency persisted for this resident.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's condition, specifically the development of a Stage 2 pressure ulcer. The Wound Care Nurse identified the pressure ulcer on the resident's sacrum but did not document any notification to the physician, the resident, or the responsible party. The notifications section on the Skin and Wound Evaluation forms for the relevant dates was left blank, indicating that required notifications were not made or not documented. The Wound Care Nurse later stated she could not recall if she had notified the physician and admitted that such a change should have prompted physician notification and a referral to the NP Wound Nurse. The resident involved had multiple complex medical conditions, including sepsis, metastatic cancer, heart failure, severe malnutrition, dysphagia, muscle wasting, and incontinence, all of which increased the risk for skin breakdown. The resident was admitted with these diagnoses and was identified as being at risk for pressure ulcers. Despite these risk factors and the development of a Stage 2 pressure ulcer, there was no evidence in the medical record that the physician was consulted or that the change in condition was communicated as required by facility policy. Interviews with facility staff, including the Wound Care Nurse, DON, NP Wound Nurse, and other nursing staff, confirmed that the expectation was to notify the physician and other relevant parties when a resident developed a new pressure ulcer. However, the staff could not provide documentation or recall specific notifications being made in this case. The facility's own policy defined the development of a Stage 2 pressure injury as a clinical complication requiring notification of the physician, resident, and representative, but this protocol was not followed for this resident.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including sepsis, metastatic cancer, severe malnutrition, dysphagia, muscle wasting, and impaired mobility. The resident was at risk for pressure ulcers and required assistance with mobility and personal care. Despite these needs, the care plan did not include measurable objectives or timeframes to address the resident's pressure wound, nor did it provide specific interventions for the resident's refusals of offloading, repositioning, and wound care treatments. Record reviews showed that the resident developed a Stage 2 pressure wound to the sacrum, and documentation indicated noncompliance with turn and repositioning as well as poor food intake. Interviews with staff revealed a lack of clarity and responsibility regarding care plan revisions, particularly in response to the development of wounds and resident refusals. The care plan was not updated to reflect the resident's changing condition or to guide staff on how to address refusals of care, despite facility policy requiring care plan review and revision upon status changes. Facility documentation and staff interviews confirmed that the interdisciplinary team did not consistently collaborate or communicate changes in the resident's condition, and the care plan was not revised to include new or modified interventions as required. This resulted in the absence of a comprehensive, individualized care plan that addressed the resident's medical, nursing, and psychosocial needs as identified in the comprehensive assessment.
Failure to Prevent Accident Hazard: Disposable Razors Left in Resident Room
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards by allowing a resident to keep disposable razors in his room without proper care planning or staff awareness. Record review showed that the resident, a male with diagnoses including diabetes, sequelae of cerebrovascular disease, major depressive disorder, anxiety disorder, and chronic pain syndrome, required supervision or limited assistance with personal hygiene. Observations on two consecutive days revealed three disposable razors beside the resident's sink. Interviews with the resident confirmed he shaves himself and that staff typically provide and retrieve the razors, but on these occasions, the razors remained in his room. Staff interviews indicated uncertainty about whether residents were permitted to keep disposable razors in their rooms, with no clear directives or policies communicated to them. The care plan for the resident did not address the use or storage of razors, and both the DON and Administrator confirmed that such permissions should be documented in the care plan but were not. The facility did not have a policy regarding the storage of disposable razors in resident rooms, and staff acknowledged potential dangers associated with residents having access to razors, including self-harm or harm to others.
Failure to Ensure Competent Wound Care and Timely Notification for Pressure Ulcer
Penalty
Summary
The facility failed to ensure that nursing staff, specifically the Wound Care Nurse (LVN), possessed and demonstrated the appropriate competencies and skill sets necessary to provide adequate nursing care and maintain resident safety and well-being. The Wound Care Nurse identified a Stage 2 pressure ulcer in a resident but did not follow facility policy regarding notification of changes to the RN Unit Manager or designee. Documentation showed that required notifications to the practitioner, resident/responsible party, dietician, and therapy services were left blank on multiple wound evaluation forms. The Wound Care Nurse was unable to recall if or when the physician was notified and admitted that documentation of such notification was not completed. The resident involved had a complex medical history, including sepsis, metastatic cancer, severe malnutrition, dysphagia, muscle wasting, and incontinence, placing him at high risk for skin breakdown and pressure injuries. Despite these risks, the care plan and physician orders for pressure reduction and skin protection were not adequately supported by timely and appropriate communication regarding the development of a new pressure ulcer. The NP Wound Nurse, who was responsible for wound care oversight, was not notified or referred the case, and upon review, stated that the resident should have been referred for further evaluation and management. Interviews with facility staff revealed confusion regarding the scope of practice for the Wound Care Nurse, particularly in relation to wound staging and notification protocols. The Wound Care Nurse had completed wound care certification but was unclear about the training received on wound staging and the requirement to notify appropriate clinical staff upon identification of a pressure ulcer. The facility's policy required notification of the attending physician upon identification of a new pressure injury, but this was not followed, and there was no documentation of physician notification or subsequent clinical actions. This lapse in competency and communication directly affected the resident's care and could have impacted his health outcomes.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection control practices during medication administration for a resident with multiple diagnoses, including Dry Eye Syndrome, Constipation, Hemiparesis, Hemiplegia, and Hyperlipidemia. During observation, the nurse placed a Gabapentin capsule on a piece of paper on top of the medication cart, rather than directly into a medication cup, and subsequently picked up the capsule with her bare hand before administering it to the resident. The nurse admitted there was no reason for placing the capsule on the cart and acknowledged that this action could put the resident at risk for infection, noting that medications should be handled in a clean manner and that hand hygiene should be performed. Further interview with the Assistant Director of Nursing confirmed that placing medication on top of the cart was not acceptable due to the risk of cross contamination, and that medications should be transferred directly from the blister pack or bottle to a medication cup. Review of the facility's medication administration policy also indicated that medications are to be administered in a manner that prevents contamination or infection, specifically instructing staff not to touch medications with bare hands. The observed actions were not in accordance with these established procedures.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to ensure personal privacy for a resident during incontinent care by not completely closing the privacy curtain, resulting in the resident's genital area being exposed. This incident occurred while the resident's roommate was present in the room. Both CNAs acknowledged that the privacy curtain was not fully closed and stated that it should have been. They also indicated that they had received resident rights training within the past year but were unaware of how long the privacy curtain had been broken, as they did not regularly work in that area. The resident involved had a history of Alzheimer's disease, vascular dementia, chronic kidney disease, major depressive disorder, and other significant medical conditions. She was always incontinent of bowel and bladder and required extensive assistance with activities of daily living. The facility's policy and care checklists required staff to provide privacy during care, including the use of privacy curtains or screens. The privacy curtain in the resident's room was broken and could not be completely closed at the time of the incident.
Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
During an observation of incontinent care provided to Resident #6, a CNA failed to change gloves or perform hand hygiene after cleaning the resident's buttocks and before handling clean items, including a draw sheet and brief. The CNA acknowledged during an interview that she forgot to change her gloves before touching the clean items and stated she had received infection control training within the past year. The Director of Nursing (DON) confirmed that staff are expected to change gloves and sanitize hands prior to handling clean items to prevent cross-contamination and infection. Resident #6 had a history of Alzheimer's disease, type 2 diabetes, hyperlipidemia, vascular dementia, anxiety, chronic kidney disease, major depressive disorder, and non-Hodgkin lymphoma. The resident was always incontinent of bowel and bladder and required extensive assistance with activities of daily living. The facility's policy required hand hygiene in accordance with established procedures, and the CNA had previously passed a competency check for incontinent care. However, the DON revealed there was no additional policy regarding hand hygiene or glove use during care.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by the conditions observed in the 300-hall shower room and several resident rooms. The 300-hall shower room was found to be in a state of disarray, with dirty clothes and linens on the floor, used personal care items scattered about, and a shower bed with a buildup of white residue and dark brown stains identified as feces. Interviews with residents and staff revealed that the shower room was not cleaned after each use, as required, and that the condition had persisted for some time. Residents expressed dissatisfaction with having to use a dirty shower, and staff acknowledged the unsanitary state of the room. In addition to the shower room, five resident rooms were observed to be cluttered and unclean. These rooms contained food crumbs, used briefs, personal items intermixed with medical supplies, and trash on the floors. The clutter and lack of cleanliness were noted to be a shared responsibility between CNAs and housekeeping staff, with charge nurses overseeing the completion of required tasks. However, it was evident that these tasks were not being consistently performed, leading to an environment that was not conducive to resident comfort or safety. Interviews with staff, including the ADON and Housekeeping Supervisor, confirmed the lack of regular cleaning and organization in both the shower room and resident rooms. The Housekeeping Supervisor admitted that the 300-hall shower room appeared not to have been cleaned in one to two weeks, and there was a recognized need for more frequent checks to ensure thorough cleaning. Despite discussions about the need for decluttering and deep cleaning, no effective plan had been implemented to address these issues, resulting in ongoing deficiencies in maintaining a clean and homelike environment for residents.
Safety Hazards in Shower and Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in one of the shower rooms and two resident rooms. In the 300-hall shower room, a razor was left on top of a shower chair, and an oxygen cylinder was left in the middle of the room. CNA J admitted to not having time to secure these items after showering two residents earlier. LVN F confirmed that the CNA's were responsible for cleaning the shower room after each use and that the razor should have been disposed of in a sharps container, while the oxygen cylinder should have been returned to the resident's room. ADON I also identified these items as safety hazards, emphasizing the risk of residents cutting themselves or the oxygen cylinder exploding if knocked over. In resident rooms, a razor was found unsecured on a counter by the sink, and multiple scissors were left in a basin on top of the vanity. LVN F stated that razors should be secured in the cabinet in the shower room and not left in resident rooms, as they pose a safety hazard, especially to cognitively impaired residents. LVN K, who was new to the 500 hall, acknowledged that residents should not have sharp objects in their rooms due to the risk of injury. ADON I reiterated that all sharp objects should be stored securely and not left in resident rooms, and that CNA's should report such findings to the charge nurse.
Infection Control Deficiencies in Linen and Room Cleanliness
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. On the 500-hall, a dirty linen barrel was observed with linen spilling over the top and sides, with the lid raised approximately 2.5 inches above the barrel. This was confirmed by CNA A, who admitted to being in a hurry and not closing the lid properly. The Director of Nursing (DON) acknowledged that while ideally the lid should be closed, it was not always feasible during rounds. This situation posed a risk of cross-contamination. In the 300-hall shower room, soiled towels with feces were left on the floor, along with a lump of feces. CNA J admitted to not having time to clean and disinfect the shower room after use, which is a required practice to prevent the spread of infection. LVN F confirmed the expectation for CNAs to clean the shower room after each use, but admitted to not checking the room on the day of the observation. The Assistant Director of Nursing (ADON) I reviewed pictures of the unsanitary conditions and expressed concerns about cross-contamination. In room #308, spots of blood were found on the floor by bed B, which LVN F had not noticed but recognized as an infection control concern. In room #506, drops of blood, a soiled dressing, and soiled linens with blood were observed, along with a clean bag of linens improperly placed on a barrel for disposing of PPE. CNA K, who was new to the 500-hall, did not initially notice these issues but acknowledged the infection control risks. ADON I reviewed the conditions and expressed concerns about cross-contamination and infection control due to the presence of blood and improper handling of linens.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, affecting 8 out of 29 employees reviewed for training requirements. The personnel records revealed that several staff members, including the Food Service Manager, Cook, Housekeeper, Maintenance Assistant, and multiple CNAs, did not receive required annual trainings. These trainings included essential topics such as resident rights, communication, abuse/neglect, dementia, QAPI, infection control, ethics, behavior health, HIV, fall prevention, restraint, and emergency preparedness. Interviews with the HR Director, Food Service Manager, and DON highlighted a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that trainings were assigned through Health Stream and that department heads were responsible for ensuring completion. However, there was no policy in place to ensure compliance, and the HR Director admitted that employees who did not complete their trainings did not receive annual wage increases. The Food Service Manager, new to her position, was unaware of how to track or ensure the completion of employee trainings. Further interviews with staff, including the Maintenance Assistant and CNA D, revealed a lack of awareness and accountability for completing annual trainings. The Maintenance Assistant could not recall the last time he completed any trainings, and CNA D mentioned that HR and the DON or ADM were responsible for ensuring training completion. Despite requests, the facility did not provide a policy on annual training requirements, indicating a systemic issue in managing and enforcing staff training compliance.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to provide mandatory effective communication training to three employees, including a cook and two CNAs, as part of their annual training requirements. The personnel records for these employees showed no evidence of communication training, despite their hire dates ranging from 2017 to 2023. Interviews with the HR Director, food service manager, and DON revealed a lack of clarity and responsibility regarding the completion and monitoring of these trainings. The HR Director mentioned that trainings were assigned through Health Stream and that employees were informed via email, but there was no policy in place to ensure completion. Additionally, the food service manager was unaware of how to track training completion, and the DON believed it was HR's responsibility to ensure compliance. The absence of a formal policy on annual training requirements and the lack of a structured process to ensure completion were significant factors leading to this deficiency. The HR Director acknowledged the importance of these trainings for maintaining up-to-date knowledge on policies and resident care. However, the facility's reliance on department heads to oversee training completion without clear guidelines or accountability measures contributed to the oversight. Interviews with staff indicated a general understanding of the importance of training, but the lack of a systematic approach to ensure compliance resulted in the deficiency noted by the surveyors.
Failure to Provide Mandatory Resident Rights Training
Penalty
Summary
The facility failed to provide mandatory effective training on the rights of residents for four employees, including the Food Service Manager, Cook, CNA B, and CNA D. The personnel records revealed that these employees did not receive annual training on resident rights, which is crucial for ensuring that staff are informed and can provide appropriate care. The HR Manager's training log showed no evidence of such training being provided annually, despite the importance of these trainings in maintaining quality care for residents. Interviews with various staff members, including the HR Director, Food Service Manager, DON, and ADM, revealed a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that trainings were assigned by corporate and that department heads were responsible for ensuring completion, but there was no policy in place to enforce this. The Food Service Manager was unaware of how to track training completion, and the DON emphasized the importance of these trainings for quality care. Despite the facility's system of withholding annual wage increases for incomplete trainings, there was no effective mechanism to ensure compliance, leading to the deficiency.
Lack of Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for four employees, including a cook and three CNAs, out of 29 reviewed for training requirements. The personnel records showed no evidence of annual QAPI training, among other essential trainings, being provided to these employees. The HR Manager's training log lacked documentation of various required trainings, such as communication, resident rights, abuse/neglect, dementia, infection control, ethics, behavior health, HIV, fall prevention, restraint, and emergency preparedness training. Interviews with the HR Director, food service manager, and DON revealed a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that trainings are assigned by corporate and that department heads are responsible for ensuring completion, but there was no policy in place to enforce this. The food service manager was unaware of how to track training completion, and the DON indicated that HR was responsible for ensuring compliance. The absence of a policy and clear accountability could lead to staff being inadequately trained, potentially affecting the quality of care provided to residents.
Deficiency in Annual Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory effective training on standards, policies, and procedures for an infection prevention and control program for three employees: a cook, CNA B, and CNA D. The personnel records review revealed that these employees did not receive annual training in infection control, among other required topics. The HR Manager's training log showed no evidence of these trainings being conducted annually for the employees in question. This lack of training could potentially affect residents by leaving staff uninformed. Interviews with the HR Director, food service manager, and DON revealed a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that trainings are assigned via Health Stream and that department heads are responsible for ensuring completion. However, there was no policy in place to ensure compliance. The food service manager was unaware of how to track training completion, and the DON indicated that HR was responsible for assigning trainings. The absence of a clear policy and accountability for training completion was evident, as no policy was provided upon request by the surveyor.
Failure to Provide Mandatory Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory effective behavioral health training for three employees, including a Cook, a Maintenance Assistant, and a CNA, as required by the facility's assessment. The personnel records review revealed that these employees did not receive annual behavioral health training, among other required trainings such as dementia, QAPI, and emergency preparedness training. The HR Manager's training log showed no evidence of these trainings being completed annually, which could potentially affect the quality of care provided to residents. Interviews with the HR Director, Food Service Manager, and DON revealed a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that while trainings are assigned via Health Stream and employees are notified by email, there is no policy in place to ensure completion. The Food Service Manager, new to her position, was unaware of how to track training completion. The Maintenance Assistant admitted to receiving email notifications but could not recall completing any trainings. The ADM confirmed that department heads are responsible for ensuring training completion, but no policy was provided to the surveyor to support this process.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was observed for call light placement, had their call light within reach. This deficiency was identified for a resident with spastic hemiplegic cerebral palsy, who was admitted with a moderate cognitive impairment and was dependent on staff for various activities of daily living. The resident's care plan indicated the need for the call light to be within reach to prevent falls and to encourage the resident to use it for assistance. However, during an observation, the call light was found tucked in a closed drawer, out of the resident's reach, which prevented the resident from calling for help when needed. Interviews with facility staff, including a CNA and the DON, revealed that the staff were aware of the resident's difficulty in using the call light and acknowledged the importance of having it within reach. The CNA had to move the call light to a more accessible position for the resident, who was then able to demonstrate its use. The facility's policy on call light accessibility emphasized the need for call lights to be accessible to residents while in bed, but this was not adhered to in the case of the resident, leading to the deficiency.
Failure to Discuss Healthcare Options with New Resident
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not discussing Medicaid coverage and healthcare provider options with a newly admitted resident. This deficiency was identified for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and type 2 diabetes mellitus with hyperglycemia. Despite the resident's minimal cognitive impairment, as indicated by a BIMS score of 14 out of 15, there was no documentation of any staff meeting with the resident to discuss medical coverage or healthcare provider options from the time of admission to the time of the survey. The resident expressed concerns about not being informed about insurance coverage and healthcare provider choices, stating that staff had told him he did not need his health insurance card anymore and that the Business Office Manager (BOM) would handle it. However, the resident reported difficulty in reaching the BOM and was left uncertain about his insurance status and healthcare needs, including a cataract surgery and dental care. The BOM and Social Worker (SW) acknowledged that they had not conducted a transitional meeting with the resident due to the absence of a family member to provide necessary documents for Medicaid application, and they were unaware of the resident's questions until the surveyor's interview.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment significantly. This deficiency involved a resident with Type 2 Diabetes Mellitus and other complications, who did not receive their prescribed insulin, Toujeo, on a scheduled night. The nursing staff did not contact the resident's primary care provider or nurse practitioner when they realized the medication was unavailable, which was against the physician's orders that specified not to hold the medication without consultation. The incident occurred when the resident's insulin was not available due to an insurance denial, and the pharmacy did not deliver the medication. The night nurse, responsible for administering the medication, failed to reorder it or notify the necessary medical personnel. The resident reported feeling upset and noted that this was not the first occurrence of such an issue. The resident's glucose levels were monitored, showing elevated levels, but no immediate adverse effects were reported. Interviews with staff revealed a breakdown in communication and protocol adherence. The nurse practitioner was not informed of the missed medication until the following day, and the facility's policy on notification of changes was not followed. The facility's management team was informed of the incident, but the night nurse did not follow the required steps to address the medication unavailability, such as contacting the pharmacy or using an alternative insulin available in the emergency kit as per the nurse practitioner's standing orders.
Failure to Administer Scheduled Insulin Dose
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals for a resident, resulting in the resident not receiving a scheduled dose of Toujeo insulin. The resident, who has Type 2 Diabetes Mellitus with complications, did not receive his nighttime dose of 80 units of Toujeo insulin as prescribed by his physician. This occurred because the medication was not delivered by the facility pharmacy, and the responsible staff did not take appropriate actions to ensure its availability. On the night of the missed dose, the night nurse, LVN G, discovered that the insulin was not available and attempted to reorder it through the computer. However, he did not notify the physician or Nurse Practitioner (NP) about the unavailability of the medication, nor did he document the incident in the progress notes. The following day, the resident expressed his upset to LVN F, who then reported the issue to the Assistant Director of Nursing (ADON) and the management team. The ADON contacted the pharmacy and resolved the issue, but the delay resulted in the resident missing his scheduled dose. Interviews with the nursing staff and the NP revealed that there was a standing order to not hold the insulin without notifying the NP, and an alternative insulin, Lantus, was available in the emergency kit. However, due to a lack of communication and documentation, the alternative was not administered. The facility's policy required the charge nurse to notify the pharmacy, the NP, and the management team in such situations, but these steps were not followed, leading to the deficiency.
Failure to Provide Mandatory Annual Training for Staff
Penalty
Summary
The facility failed to provide mandatory effective training on abuse, neglect, exploitation, and misappropriation for two employees, a cook and a CNA, as part of their annual training requirements. The personnel records for the cook, hired on 11/16/2023, and CNA D, hired on 07/24/2017, showed no evidence of receiving the required annual training in several critical areas, including communication, resident rights, abuse/neglect, dementia, QAPI, infection control, ethics, behavior health, HIV, fall prevention, restraint, and emergency preparedness. This lack of training could potentially affect residents by leaving staff uninformed and unprepared to provide quality care. Interviews with the HR Director, food service manager, DON, and ADM revealed a lack of clarity and responsibility regarding the completion of annual trainings. The HR Director stated that trainings are assigned via Health Stream and that department heads are responsible for ensuring completion, but there was no policy in place to enforce this. The food service manager was unaware of how to track training completion, and the DON and ADM reiterated the importance of completing trainings but did not provide a clear process for ensuring compliance. The facility did not provide a policy on annual training requirements when requested by the surveyor.
Failure to Provide Mandatory Ethics Training
Penalty
Summary
The facility failed to provide mandatory effective ethics training for one of the 29 employees reviewed, specifically a cook, which could potentially affect residents by leaving them uninformed due to the lack of staff training. The personnel records for the employee in question showed a hire date of 11/16/2023, but there was no evidence of the required annual ethics training or other mandatory trainings such as communication, resident rights, abuse/neglect, dementia, QAPI, infection control, behavior health, HIV, fall prevention, restraint, or emergency preparedness training. This lack of training was confirmed through interviews with various staff members, including the HR Director, Food Service Manager, and DON, who all acknowledged the importance of completing these trainings to ensure quality care for residents. The HR Director stated that annual trainings are available through Health Stream and are assigned by corporate, with department heads responsible for ensuring completion. However, there was no policy in place to ensure employees completed their trainings, and the Food Service Manager, who was new to her position, was unaware of how to track or enforce training completion. The DON and ADM both emphasized the importance of these trainings for maintaining up-to-date knowledge and providing quality care, but the facility lacked a structured approach to ensure compliance. The surveyor requested a policy on annual training requirements, but none was provided before the survey exit.
Deficiency in Annual Dementia Training for CNA
Penalty
Summary
The facility failed to provide mandatory effective in-service training for nurse aides on dementia care, specifically for one of the five nurse aides reviewed, identified as CNA C. The personnel records for CNA C, who was hired on June 1, 2021, showed no evidence of annual dementia training, QAPI training, behavior health training, or emergency preparedness training. This lack of training could potentially affect residents by leaving them uninformed due to the staff's insufficient training. Interviews with the HR Director, DON, and ADM revealed that annual trainings are available through Health Stream and are assigned by corporate. However, there was no policy in place to ensure that employees complete these trainings. The HR Director mentioned that employees are informed of their assigned trainings via email, and department heads are responsible for ensuring completion. It was noted that employees who do not complete their annual trainings do not receive their annual wage increase. Despite these measures, the facility did not have a policy on annual training requirements, which contributed to the deficiency.
Inadequate Respiratory Care Due to Untrained Staff Handling Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who was cognitively intact and had a history of heart failure and morbid obesity, was observed being transferred from bed to wheelchair by two CNAs. During the transfer, the resident's nasal cannula was removed, and the oxygen tubing was handled by a CNA who had not received training on oxygen use or competency training on changing the oxygen tubing. The CNA held the cannula in her hand during the transfer and later connected it to an oxygen tank attached to the resident's wheelchair without proper training. Interviews with the CNAs, LVN, and DON revealed a lack of clarity and training regarding the handling of oxygen equipment by CNAs. The LVN believed that CNAs were allowed to attach the oxygen tubing but not adjust the settings, while the DON initially believed CNAs were trained to handle the tubing but later acknowledged that it was not part of their competency evaluation training. The facility did not have a policy in place regarding the handling of oxygen equipment by CNAs, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications, as observed in the case of Resident #1. During an observation, a small, white, intact oval pill was found on the nightstand next to Resident #1's bed, and a beige capsule was found on the floor near the resident's doorway. Resident #1, who was moderately cognitively impaired and had a history of cerebral infarction and chronic pain, was unable to identify the medication left on the nightstand. LVN A, who was not aware of any self-administration assessment for the resident, confirmed the presence of the unidentified pill and expressed concern about the potential for medication misuse or adverse effects if the resident did not take her prescribed medication or if another resident ingested it. Further investigation revealed that MA B had administered medications to Resident #1 earlier in the morning but was unaware that the resident might have pocketed the pills. MA B identified the pill on the nightstand as Tylenol Extra Strength, prescribed to the resident, but could not identify the capsule found on the floor. MA B acknowledged the risk of the resident not taking her pain medication, which could lead to unmanaged pain, or the possibility of double dosing if the resident saved the medication for later. Additionally, there was a concern that other residents who wander could ingest the medication, leading to potential adverse effects. In another instance, a small, round white pill was found on the floor in the 300 hall. LVN C acknowledged the pill but could not identify it and noted the safety issue of residents potentially ingesting unidentified medications. LVN C also left the medication cart unlocked and unattended, which was acknowledged as a security risk by both LVN C and the DON. The DON emphasized the importance of securing medications to prevent unauthorized access, as leaving the cart unlocked could lead to residents accessing medications and experiencing adverse effects.
Privacy Breach During Catheter Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during catheter care, as observed by surveyors. The incident involved two CNAs who left the resident's bedroom door open and did not fully draw the privacy curtain while performing catheter care. This was contrary to the facility's expectations and the resident's rights to privacy and dignity. The resident, who had multiple medical conditions including UTI, Type 2 Diabetes, and hemiplegia, expressed feeling like an animal due to the lack of privacy during the procedure. Interviews with the CNAs involved, as well as other staff members, confirmed that the standard practice was to close doors and curtains to maintain privacy during care. The CNAs acknowledged the oversight, with one admitting to being nervous during the observation. The facility's Administrator and LVNs reiterated the importance of maintaining privacy to protect residents' dignity and prevent feelings of embarrassment. Despite the absence of a specific catheter care policy, the facility's manual and competency validation documents emphasized the need for privacy during such procedures.
Inadequate Catheter Care Leads to Potential Trauma Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder, which could lead to urinary tract infections and trauma. The resident, who had multiple diagnoses including UTI, Type 2 Diabetes, and hemiplegia, was dependent on staff for toileting hygiene and had an indwelling catheter. During an observation of catheter care, two CNAs did not hold the catheter at the insertion site, which is necessary to prevent trauma and cross-contamination. Instead, the catheter was held at the anchor on the resident's thigh, increasing the risk of pulling the catheter out and causing trauma due to the inflated balloon. Interviews with staff confirmed that the catheter should be held 2-3 inches from the urethral meatus during cleaning to avoid trauma and infections. The facility's Director of Nursing was unable to provide a catheter care policy but did provide a clinical competency validation document that emphasized minimal manipulation of the catheter. The failure to adhere to proper catheter care procedures placed the resident at risk for trauma and diminished quality of life.
Deficiencies in Nurse Aide Competency and Care Procedures
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in essential care skills, as evidenced by the actions of CNA B and CNA C. During an observation of perineal care for a resident, CNA B used the same surface of a wipe multiple times to clean the resident's glans penis, contrary to facility policy, which requires using a clean surface for each wipe to prevent infection. Additionally, CNA B did not clean the shaft of the penis or the scrotum, which are necessary steps in the procedure. CNA B admitted to not receiving training on perineal care during her five months at the facility. In another instance, CNA C failed to perform catheter care according to professional standards for a resident with an indwelling catheter. CNA C held the catheter close to the anchor on the resident's thigh instead of near the urethral meatus, which is necessary to avoid trauma and infection. CNA C acknowledged the correct procedure during an interview but did not follow it during the care observation. The resident's care plan indicated a need for substantial assistance with personal hygiene and a risk for infection, highlighting the importance of proper catheter care. Interviews with facility staff, including LVN B and LVN C, revealed that CNAs were trained by peers during orientation, and there was no designated nurse for training. Competency checks were supposed to be conducted by LVN B, but the process appeared inconsistent. The Director of Nursing (DON) was identified as responsible for ensuring staff training and competency, but the DON was unavailable for comment. Despite the facility's documentation showing that CNA B and CNA C met competency requirements, the observed deficiencies indicate a gap in training and adherence to care procedures.
Inaccurate Documentation of Vital Signs
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of vital signs. On a specific date, a Medical Assistant (MA) documented a heart rate of 37 for a resident, which was incorrect and should have been 87. The MA admitted to making the error due to not wearing glasses and was unable to correct it in the Electronic Medical Record (EMR) as only nurses had the capability to do so. The MA also failed to report the error to a nurse for correction. This inaccuracy in documentation could potentially place residents at risk for improper care. The resident involved had multiple diagnoses, including UTI, Type 2 Diabetes, Morbid Obesity, Hemiplegia, Anxiety Disorder, Major Depressive Disorder, Obstructive and Reflux Uropathy, Dysphagia, Congestive Heart Failure, Hyperlipidemia, and Hypertension. Despite the incorrect heart rate documentation, the resident reported feeling fine without symptoms of low heart rate. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) were informed of the error, but the issue was not addressed promptly, highlighting a lapse in the facility's adherence to its policy on accurate and timely documentation in medical records.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper infection control practices observed during care for two residents. For the first resident, CNA B and CNA C did not follow proper procedures during perineal care. They failed to remove wipes from the package before starting the procedure, which could lead to cross-contamination. Additionally, CNA B used the same surface of a wipe multiple times on the resident's glans penis and did not clean the shaft of the penis or the scrotum, contrary to the facility's policy. For the second resident, CNA C did not adhere to proper infection control practices during catheter care. Similar to the first incident, wipes were not removed from the package beforehand, risking contamination. CNA C also held the catheter incorrectly, close to the catheter anchor instead of near the urethral meatus, which could increase the risk of infection. These actions were not in line with the facility's policy and the Lippincott procedures for indwelling urinary catheter care. Interviews with the CNAs and LVNs revealed a lack of adherence to infection control procedures, despite training being provided. The facility's policies clearly outlined the correct procedures for perineal and catheter care, emphasizing the importance of using a new wipe for each stroke and holding the catheter correctly to prevent infection. The failure to follow these procedures was acknowledged by the staff, indicating a gap in the implementation of the infection prevention and control program.
Failure to Notify Physician and Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify a resident's physician and responsible party when the resident exhibited significant changes in physical condition, including right-sided facial drooping, edema, and coolness to both hands. This deficiency was identified for one resident who was reviewed for notification of changes. The resident had a medical history of Alzheimer's Disease, muscle wasting, weakness, hypertensive heart disease, and chronic kidney disease. On the morning of the incident, a CNA observed the resident with symptoms suggestive of a stroke, such as facial drooping and slurred speech, and reported these to an LVN. However, the LVN did not immediately assess the resident or notify the physician. The resident's responsible party discovered the symptoms later that day and expressed concerns to the facility staff, but the physician was not informed until the following day. The resident's symptoms persisted, and further medical evaluation revealed a new cerebral infarct. Interviews with facility staff indicated a lack of immediate action and communication regarding the resident's change in condition. The LVN admitted to not notifying the physician on the day the symptoms were first observed, believing there was no immediate need. The facility's Director of Nursing (DON) and other staff members were aware of the situation but did not take timely action to address the resident's condition or ensure proper notification. The DON acknowledged that a change in condition should be reported promptly, yet there was a delay in communication and assessment. This failure to act promptly and notify the appropriate parties resulted in the identification of an Immediate Jeopardy situation, highlighting the risk of delayed medical intervention and potential decline in the resident's health.
Failure to Timely Address Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who exhibited symptoms of a significant change in condition. On the morning of 4/20/24, a CNA observed that the resident had facial drooping, a cold right hand, and slurred speech, which were indicative of a possible stroke. The CNA reported these symptoms to LVN A, who did not assess the resident immediately or notify the physician or nurse practitioner. The resident's responsible party (RP) later noticed the symptoms and expressed concern, but it was not until the following day that medical professionals were informed and began to take action. The resident had a history of Alzheimer's Disease, muscle wasting, weakness, hypertensive heart disease, and chronic kidney disease. Despite these conditions, the symptoms observed on 4/20/24 were not promptly addressed by the nursing staff. LVN A admitted to not notifying the physician or nurse practitioner on the day the symptoms were first reported, believing there was no immediate need. This delay in notification and assessment led to a failure in providing care according to professional standards, as the resident's symptoms were not evaluated or treated in a timely manner. The facility's inaction resulted in an Immediate Jeopardy (IJ) situation, as the delay in medical intervention could have led to a decline in the resident's health. The IJ was identified on 4/24/24, highlighting the facility's failure to ensure prompt notification of changes in a resident's condition. The lack of documentation and communication among staff members contributed to the oversight, as the symptoms were not recorded in the nursing progress notes for 4/20/24, and the responsible party was not informed of the resident's condition until 4/21/24.
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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