Harbor Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 6211 Old Pearsall Road, San Antonio, Texas 78242
- CMS Provider Number
- 676478
- Inspections on file
- 43
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Harbor Valley Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple psychiatric and cognitive diagnoses, but intact cognition per BIMS, had an established expectation to remain for LTC. The facility issued a 30‑day discharge notice for nonpayment, informed the resident of appeal rights, and listed alternate discharge locations. Before the effective discharge date, the resident was sent to a hospital by EMS for a CT and evaluation of neck and spine pain. When the hospital attempted to return the resident, the administrator, following a corporate directive, refused readmission, stating the facility could not meet the resident’s needs, even though neither the resident nor the hospital had been informed at the time of transfer that she would not be allowed back. The medical record did not contain documentation of the reason for refusing readmission or the specific basis for transfer/discharge as required by facility policy, and there was no documented preparation or orientation for a permanent discharge at the time of the hospital transfer.
Surveyors found that medications and medicated ointments were left unsecured at the bedside of three cognitively intact residents, despite facility policy prohibiting bedside storage and self-administration. Staff interviews confirmed that no residents were authorized to self-administer medications, and that all drugs and biologicals should be stored securely and only accessible to authorized personnel.
A staff member with facial hair was observed checking food temperatures in the kitchen without wearing a beard net, in violation of facility policy. Despite being reeducated on the policy and acknowledging its importance, the staff member did not comply, and the DM, who witnessed the incident, did not intervene. Other dietary staff confirmed the policy requirements and the need to prevent food contamination.
A deficiency was identified when a staff member entered a resident's room on droplet precautions for COVID-19 without wearing PPE, despite clear signage and available supplies. Interviews with the Infection Preventionist, ADONs, DON, and administrator revealed uncertainty about the timing of recent infection control training, and the facility could not provide its infection control policy to surveyors. The resident had severe cognitive impairment and was under isolation protocols, but staff failed to consistently follow required infection prevention measures.
A CNA used abrupt force to transfer a male resident with moderate cognitive impairment and behavioral symptoms to his bed, holding his arms behind him and pressing on his chest, rather than following the care plan interventions for managing resistive behaviors. The incident was captured on video and reported by the resident's family, confirming a failure to ensure the resident's right to be free from abuse.
A resident with Alzheimer's Disease and hypertension, admitted for hospice respite care, was transferred by two CNAs without the required mechanical lift, despite clear physician orders and care plan interventions documented in the Kardex. The CNAs did not review the Kardex or consult the charge nurse before performing the manual transfer, resulting in a failure to implement the comprehensive care plan as assessed.
A resident with severe cognitive impairment and primarily Spanish-speaking was not treated with dignity and respect by staff, who failed to engage or communicate effectively. Despite a care plan addressing the language barrier, staff did not greet the resident or seek translation assistance, leading to unmet needs and distress for the resident and family.
A resident with severe cognitive impairment and dysphagia did not receive necessary assistance during meals, as staff failed to set up meal trays properly, including raising the bed and cutting meat. Communication barriers due to language differences further hindered the resident's ability to express needs, leading to inadequate care during meal times.
The facility failed to ensure safe mechanical lift transfers for two residents, as staff did not lock or widen the base of the lift during transfers, leading to potential accident hazards. In one instance, a wheelchair got stuck, causing both the resident and the wheelchair to be lifted into the air. In another case, a CNA did not lock the lift's base, requiring intervention from another staff member. The DON confirmed the importance of following safety procedures to prevent falls and injuries.
A facility failed to document a resident's advance directive preferences in their electronic medical record. Despite the resident's admission packet indicating a preference for a DNR order and feeding restrictions, the social worker was unaware and considered the resident a full code. The oversight occurred because the director of marketing did not inform the social worker of the resident's wishes, leading to a potential risk of the resident's end-of-life preferences being dishonored.
A facility failed to update a resident's MDS assessment to reflect the discontinuation of insulin, leading to an inaccurate depiction of the resident's medication regimen. The MDS Coordinator confirmed the error, noting that the resident had no current insulin orders, contrary to what was recorded. This oversight could risk improper care due to inaccurate assessments.
A facility failed to ensure a safe environment by leaving a disposable razor in a resident's room and not securing storage closets containing hazardous items. The unlocked closets on two halls contained products that could be harmful if ingested, posing a risk to residents, especially those who wander. The DON acknowledged the oversight, noting the absence of a policy for storing hazardous items.
The facility failed to store medications requiring refrigeration properly, with lorazepam found on a medication cart instead of in a fridge. Additionally, expired medical supplies were discovered in storage rooms. An LVN expressed confusion about medication storage requirements, and the DON confirmed that lorazepam should be refrigerated to maintain effectiveness.
A medication error rate of 6.45% was identified in a facility due to improper insulin administration by an LVN. A resident with type 2 diabetes was administered insulin lispro and insulin glargine without priming the pens, contrary to manufacturer instructions. The facility lacked a specific policy for insulin pen use, contributing to the error.
A facility failed to coordinate hospice care and maintain necessary documentation for a resident with cerebral atherosclerosis and chronic kidney disease. The resident's hospice documents, including the Physician Certification of Terminal Illness and Hospice election form, were incomplete, and the most recent plan of care and hospice physician orders were unavailable. Despite being on hospice since 2021, the facility did not ensure proper documentation, risking inadequate end-of-life care.
A medical assistant in an LTC facility failed to sanitize a blood pressure cuff between uses on two residents, contrary to the facility's infection control policy. The assistant believed cleaning was only necessary after every two residents, which was incorrect. The Director of Nursing confirmed the need for sanitization between each use to prevent infections.
A resident's privacy was compromised when their buttocks were visible from the hallway during care due to the absence of a privacy curtain in their room. Staff were aware of the missing curtain and typically closed the door to provide privacy, but the door was left open during this incident.
A resident with chronic respiratory failure, type 2 diabetes, and hypertension was mistakenly given Seroquel and Ativan, which were not prescribed. The error occurred because the MA failed to properly identify the resident before administering the medications, despite the presence of the resident's RP who did not correct the MA. The facility's policy on verifying resident identity was not followed.
A resident's call button in their bedroom was found non-functional with exposed wires, posing a risk of harm. The resident, a 94-year-old male with dementia and other health issues, was dependent on staff for ADLs. The malfunction was due to disconnected wires, as confirmed by the maintenance director.
The facility failed to ensure that a resident was seen by a physician at least once every 60 days after the initial 90 days following admission. The resident had a gap of 188 days between physician visits, which was confirmed through record reviews and interviews. The DON was unable to recall the facility's policy on physician visit frequency.
A facility failed to ensure all drugs and biologicals were stored in locked compartments. An LVN left a medication cart unlocked and unattended while answering a call light. The LVN acknowledged the cart should have been locked and stated she was educated on medication security during orientation. The DON confirmed that medication carts should be locked when not in use and mentioned that hourly rounds are conducted to check if medication carts are locked.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. An expired bottle of eyewash solution was found above the handwashing sink in the kitchen. Cook B confirmed the expiration and was unaware of the frequency of checks. The facility's policy states that discontinued, outdated, or deteriorated drugs or biologicals should not be used.
Failure to Readmit Hospitalized Resident and Lack of Documented, Organized Discharge
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a hospital transfer and failure to document sufficient preparation and orientation to ensure a safe and orderly transfer or discharge. The resident was an adult female with delusional disorder, borderline personality disorder, bipolar disorder, dementia, depression, and anxiety, who had been admitted for LTC. Her most recent annual MDS showed a BIMS score of 13, indicating no cognitive impairment, and Section Q indicated there was no active discharge planning for community return. A care plan entry dated and cancelled on the same day stated that her discharge planning would honor her personal wishes and that, based on care plan meetings and discussions, the expectation was for her to remain in the facility for LTC. The facility issued a 30‑day discharge letter for nonpayment on 12/01/2025, citing failure to pay for the stay after reasonable and appropriate notice. The A/R statement showed an outstanding balance of $2017.60 and no payments since April 2025. Nursing notes documented that the administrator and another staff member delivered the discharge notice and that the resident responded by yelling, cursing, and stating she had a court order indicating she did not owe the facility anything. The discharge letter listed a home address or another nursing facility as the discharge locations, gave an effective discharge date of 01/01/2026, and informed the resident of her right to appeal through the state process within 90 days. The business office manager (BOM) stated that the resident was told she had 30 days to appeal and that she could have appealed any time between 12/01 and 12/31 to stop the discharge. On 12/10/2025, nursing notes documented that the resident was picked up by EMS and sent to a hospital for a CT scan and evaluation of neck and upper spine pain. The DON stated the CT had been ordered a week or two earlier but the resident had repeatedly cancelled or refused the appointment. When the hospital later called to give report and return the resident, the DON reported being told by the administrator that the resident was not allowed back because the facility could not meet her needs, and the hospital had not been informed at the time of transfer that the facility would refuse readmission. The administrator confirmed that the corporate office directed that the resident not be readmitted, acknowledged that the resident had not been notified before transfer that she would be refused return, and believed the DON had informed the hospital, which the DON denied. The ombudsman reported that the BOM told her corporate had directed that the resident not be allowed to return, and that she informed the BOM this was not permissible because the resident had the right to appeal the discharge. The facility’s own policies required that residents not be transferred or discharged while an appeal is pending unless remaining would endanger health or safety, and required documentation in the medical record of the reasons for any transfer or discharge, including specific unmet needs, facility attempts to meet those needs, and services available at the receiving facility. The survey record indicates that the facility did not document in the resident’s medical record the reason for not accepting her back after hospitalization. There is no documentation that the facility updated the discharge notice information when the decision was made not to readmit her from the hospital, nor is there documentation that the resident was prepared or oriented for a permanent discharge at the time she was sent out for a CT scan. Interviews with the resident, ombudsman, BOM, DON, and administrator consistently showed that the resident was transferred for diagnostic evaluation and then denied readmission based on a corporate directive, without prior notice to the resident or hospital and without the required documentation in the medical record.
Unsecured Medications and Medicated Products Found at Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as required by professional standards and facility policy. During observations and interviews, it was found that three residents had medications or medicated products at their bedsides, despite not being authorized for self-administration. Specifically, one resident had two medication cups containing cough syrup at her bedside for three days, and two other residents each had a jar of medicated mentholated ointment on their bedside tables, which they reported using on their feet. Record reviews confirmed that all three residents were cognitively intact and received their medications from nursing staff, with no authorization for self-administration. Interviews with staff, including medication aides, LVNs, and the DON, consistently indicated that medications were not to be left at the bedside for any resident, as this could allow access by other residents or result in improper use. The facility's own policy required all drugs and biologicals to be stored securely and only accessible to authorized personnel. The observations and interviews demonstrated that the facility did not follow its own medication storage policy, resulting in medications and medicated products being left unsecured at residents' bedsides. This practice was identified for three residents during the survey and was acknowledged by staff as not being in accordance with facility procedures.
Failure to Enforce Beard Net Policy During Food Handling
Penalty
Summary
A deficiency was identified when a staff member with facial hair was observed in the kitchen checking food temperatures without wearing a beard net, as required by the facility's policy. The staff member acknowledged being reeducated on the beard net policy a year prior and stated that all kitchen staff were responsible for following this policy. Despite this, he did not wear a beard net before checking food temperatures, citing allergies as the reason, and admitted to notifying the Dietary Manager (DM) about his allergies before his shift. The staff member also confirmed that he was still required to wear a beard net regardless of the length of his facial hair. Other dietary staff interviewed confirmed their understanding of the beard net policy and the importance of its adherence to prevent hair from contaminating food. The DM stated that all kitchen staff and anyone entering the kitchen were required to wear a beard net or be clean-shaven when handling food, and that he conducted rounds to ensure compliance. However, the DM observed the staff member not wearing a beard net while checking food temperatures and did not intervene or provide a reason for not taking action. The facility's Staff Attire policy, revised in January 2025, specifies that all staff must have hair confined in a hair net or cap and facial hair properly restrained.
Failure to Ensure Staff Compliance with PPE Protocols for Resident on Droplet Precautions
Penalty
Summary
A deficiency occurred when staff failed to follow established infection prevention and control protocols for a resident who was on droplet precautions due to a COVID-19 diagnosis. On the morning of 11/12/25, electronic monitoring footage showed a staff member entering the resident's room without donning any personal protective equipment (PPE), placing a meal tray on the bedside table, interacting with the resident, and then exiting the room. This was despite clear signage on the door indicating droplet precautions and the presence of a PPE supply bin outside the room. The resident's care plan specifically required isolation with droplet precautions, including proper donning and doffing of PPE when entering and exiting the room. Interviews with facility staff, including the Infection Preventionist, ADONs, DON, and the administrator, revealed inconsistencies and uncertainty regarding the frequency and timing of staff reeducation on infection control practices. While staff members acknowledged the importance of donning PPE before entering and exiting rooms under droplet precautions, several were unable to recall when the most recent infection control training or in-service had occurred. The Infection Preventionist and other leaders stated that oversight was conducted through rounds and periodic competencies, but could not provide specific details or documentation of recent staff education on infection control. Additionally, the facility was unable to provide the requested infection control policy to the surveyor before the exit. The resident involved had a history of dementia, weakness, and COVID-19, and was assessed as having severe cognitive impairment. The failure to ensure staff compliance with PPE protocols, as well as the lack of clear documentation and timely reeducation on infection control, contributed to the deficiency identified during the survey.
Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A certified nursing assistant (CNA) used abrupt force to place a male resident with moderate cognitive impairment and behavioral symptoms onto his bed. The resident, who had diagnoses including hepatic encephalopathy, dementia, anxiety disorder, and delusional disorder, was known to be resistive to care and exhibited aggressive behaviors such as threatening and attempting to strike staff. On the day of the incident, the resident was observed ambulating in the hallway without proper clothing, entered another resident's room, and became aggressive when redirected by staff. During the attempt to guide the resident back to his room, the CNA held both of the resident's arms behind him, pushed him forcefully onto the bed, and pressed on his chest when the resident tried to get up. The incident was captured on video and witnessed by the resident's family member, who reported it to the facility administrator. Interviews with staff and review of video footage confirmed that the CNA used forceful physical contact during the transfer, which was not in accordance with the resident's care plan interventions for managing resistive and aggressive behaviors. The care plan specified the use of reassurance, clear explanations, and leaving and returning later if the resident resisted care, rather than physical force. The CNA did not request assistance from other staff during the incident, despite the resident's known behavioral challenges. The facility's investigation and interviews with other staff and residents indicated that this was the only incident of abuse involving this resident, and no physical injury was noted upon assessment. However, the use of forceful physical contact constituted a failure to ensure the resident's right to be free from abuse, neglect, and physical punishment, as required by facility policy and regulatory standards.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Alzheimer's Disease and hypertension, who was admitted for hospice respite care. The resident had physician orders and care plan interventions specifying the use of a mechanical lift with two staff for all transfers. These requirements were documented in the resident's care plan and Kardex, which staff are trained to review prior to providing care. On one occasion, two CNAs transferred the resident from bed to a high-back wheelchair without using the required mechanical lift. Neither CNA reviewed the resident's Kardex or consulted the charge nurse to confirm the transfer status before performing the transfer. The family member of the resident observed the transfer and confirmed that a mechanical lift was not used. Both CNAs later acknowledged that they did not check the Kardex prior to the transfer and proceeded with a manual transfer involving two staff members. Interviews with facility staff, including the DON, MDS Nurse, and Administrator, confirmed that the resident's transfer status was clearly documented and that staff had been trained to use the Kardex to determine transfer requirements. The MDS Nurse indicated that the transfer status was entered into the Kardex the day after admission. The failure to follow the care plan and physician orders for mechanical lift transfers was identified as a deficiency, as it did not meet the resident's assessed needs and placed the resident at risk.
Failure to Respect Resident's Communication Needs
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by multiple instances where nursing staff did not engage with the resident in a manner that recognized her individuality and communication needs. The resident, who was primarily Spanish-speaking and had severe cognitive impairment, was not greeted or engaged by staff upon entering her room. Staff members did not introduce themselves or explain the purpose of their visits, and they failed to seek assistance from Spanish-speaking staff to facilitate communication. The resident's care plan indicated a communication problem due to a language barrier, with a family request for a Spanish-speaking CNA each shift. Despite assurances from the Director of Nursing (DON) that Spanish-speaking staff were available, video evidence showed staff ignoring the resident's attempts to communicate in Spanish. The resident expressed her needs, such as requesting different food or assistance with her cell phone, but staff did not respond appropriately or seek translation help. Interviews with family members and staff confirmed the communication issues, with family members expressing distress over the lack of engagement and understanding from staff. The DON acknowledged that staff did not follow protocol, which required greeting the resident and seeking translation assistance. The facility's policy on residents' rights emphasized the right to be treated with dignity and respect, which was not upheld in this case.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically during meal times. The resident, who had severe cognitive impairment, dysphagia, and other health issues, required assistance with meal setup, including raising the head of the bed, cutting meat, and positioning the bedside table for easy access. However, staff consistently neglected these tasks, leaving the resident unable to comfortably and effectively consume meals. Observations and video reviews revealed that staff members, including a CNA and an AD, did not follow proper protocol when delivering meal trays to the resident. They failed to remove the plate cover, open condiments, or set up utensils, and did not ensure the resident's bed was positioned correctly for eating. The resident, who primarily spoke Spanish, also faced communication barriers as not all staff members could understand or communicate in her language, further complicating her ability to express her needs. Interviews with family members and staff confirmed these deficiencies. Family members expressed concerns about the lack of Spanish-speaking staff and the inadequate assistance provided during meals. The DON acknowledged that staff did not adhere to the facility's policy on meal assistance, which required setting up the meal tray and ensuring the resident could access her food easily. This oversight resulted in the resident struggling to eat independently and comfortably, highlighting a significant lapse in care for residents requiring assistance with meals.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents received proper assistance during mechanical lift transfers, leading to potential accident hazards. In the case of Resident #2, CNA F did not lock the mechanical lift or widen its base while transferring the resident from a wheelchair to a bed. This resulted in the wheelchair getting stuck between the legs of the lift, causing both the resident and the wheelchair to be lifted into the air until CNA G intervened. Despite the intervention, CNA F continued the transfer without locking or widening the base, which could have led to a fall. For Resident #3, CNA I operated the mechanical lift without locking its base during the transfer from a wheelchair to a bed. CNA H noticed the oversight and applied the brake with her foot while Resident #3 was being lowered. CNA I acknowledged the failure to lock the base, which is necessary to prevent the lift from moving and ensure stability during transfers. Both CNAs involved in the transfer recognized that the resident could have been injured if a fall had occurred. The Director of Nursing (DON) confirmed that staff should lock the base of the mechanical lift and widen it for stability during transfers to prevent falls and injuries. The manufacturer's instructions also emphasized the importance of keeping the base legs in the widest position and ensuring that the lift's casters are not locked during lifting and lowering. These practices were not followed, leading to the deficiencies observed during the survey.
Failure to Document Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to ensure that a resident's desire to formulate an advance directive was properly documented in his electronic medical record. The resident, who was admitted with several chronic conditions including type 2 diabetes, hypertension, atrial fibrillation, and chronic kidney disease stage 4, was initially documented as a full code in his baseline care plan. However, the admission packet contained an Advanced Directive Acknowledgement form indicating the resident's preference for a Do Not Resuscitate (DNR) order and feeding restrictions, which was signed by the legal representative and a facility representative. During interviews, the social worker (SW) was unaware of the resident's advance directive preferences and stated that the resident was a full code. The SW mentioned that the director of marketing, who filled out the paperwork with the resident and his family, failed to notify him of the resident's wishes. The resident and his representative confirmed that they had completed the paperwork to reflect the resident's preferences. The oversight in communication and documentation could lead to the resident's end-of-life wishes being dishonored.
Inaccurate MDS Assessment for Resident's Medication
Penalty
Summary
The facility failed to ensure that a resident's Annual Minimum Data Set (MDS) assessment accurately reflected their current medication regimen. Specifically, the MDS assessment indicated that the resident was receiving insulin injections, despite the fact that the resident's insulin had been discontinued several months prior. This discrepancy was identified during a review of the resident's records, which showed that the last insulin order was discontinued on December 15, 2023, and there were no active orders for insulin as of August 28, 2024. During an interview, the MDS Coordinator confirmed that the resident did not have any current orders for insulin and acknowledged that the MDS should accurately depict the medications and care the resident receives. The facility's policy on the Resident Assessment Instrument (MDS 3.0) emphasizes the importance of conducting comprehensive assessments to describe the resident's capabilities and identify impairments, which are crucial for planning appropriate care. The failure to update the MDS assessment could potentially place residents at risk of receiving improper or incorrect care due to inaccurate assessments.
Failure to Secure Hazardous Items and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for Resident #86 and in two storage closets. During an observation, a disposable razor was found in a basin by Resident #86's bedside. The resident, who was in bed at the time, stated that staff would bring supplies for a bed bath and assist with shaving, but he was unaware of how long the razor had been there. This oversight posed a potential hazard to the resident, who did not notice the razor's presence. Additionally, the facility did not secure storage closets on Hall 100 and Hall 200, which contained potentially hazardous items such as perineal skin cleanser, lotion, zinc oxide skin protectant, shave gel, mouthwash, fluoride toothpaste, hand sanitizer, germicidal wipes, and disposable razors. These closets were observed to be unlocked and lacked locking mechanisms. The supply coordinator confirmed that the closets were not locked, posing a risk if residents accessed and ingested the products. The Director of Nursing acknowledged the risk, especially for residents who wandered, such as those residing on Hall 200. No policy for the storage of potentially hazardous items was provided.
Improper Storage of Medications and Expired Supplies
Penalty
Summary
The facility failed to store medications and biologicals under proper temperature controls, specifically on the 100 hall medication cart. During an observation, it was found that the cart contained nine glucometers stored in individual boxes, with logs for testing that did not match the serial numbers of four glucometers. An insulin lispro pen with an open date was being used for a resident, and there were three bottles of lorazepam with refrigerate stickers stored on the cart. LVN E, during an interview, expressed uncertainty about whether medications labeled for refrigeration needed to be refrigerated and mentioned confusion about the frequency of glucometer checks. Additionally, expired medical supplies were found in various storage rooms, including gauze, peristoma cleanser, adhesive remover, IV catheters, and peroxide. The Director of Nursing (DON) stated that the expired supplies were not used and needed to be discarded. The DON also mentioned that the glucometers were checked weekly, following manufacturer guidelines, and that insulin expiration dates varied. The DON acknowledged that lorazepam should be refrigerated and could lose therapeutic effectiveness if not stored properly. The facility's policy required medications needing refrigeration to be stored in a refrigerator located in a secured location.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 6.45% due to errors in insulin administration for a resident. The resident, an elderly female with diagnoses including senile degeneration of the brain and type 2 diabetes mellitus, was prescribed insulin lispro and insulin glargine. During an observation, a Licensed Vocational Nurse (LVN) administered these insulins without priming the insulin pens, which is a necessary step to ensure accurate dosing. The LVN did not follow the manufacturer's instructions for priming the insulin pens, which involves turning the dose knob to select 2 units and ensuring insulin is visible at the needle tip. This oversight was confirmed during interviews with the LVN and the Director of Nursing (DON), who acknowledged the importance of priming to ensure accurate insulin administration. The facility lacked a specific policy for insulin pen administration, which contributed to the medication error.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not ensure that the most recent Physician Certification of Terminal Illness and Hospice election form were completed and included in the hospice documents for the resident. Additionally, the most recent plan of care, list of hospice personnel involved in the care, and hospice physician orders were not available at the facility. This lack of documentation and coordination could potentially place residents receiving hospice services at risk of inadequate end-of-life care. The resident in question was admitted with diagnoses including cerebral atherosclerosis and chronic kidney disease stage 2, and had been receiving hospice care since 2021. Despite this, the facility's medical records department had not ensured that all necessary hospice documents were obtained and maintained. Interviews revealed that the medical records staff had contacted the hospice company for the documents but did not follow up to ensure receipt. The Director of Nursing (DON) was unaware that records were still pending and had instructed nursing staff to update hospice binders. The facility's policy outlined specific responsibilities for coordinating hospice care, but these were not fulfilled, leading to the deficiency.
Infection Control Lapse with Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA G) who did not sanitize a blood pressure cuff between uses on different residents. During an observation, MA G was seen taking the blood pressure of one resident and then placing the cuff back on the cart without sanitizing it. Subsequently, MA G used the same unsanitized cuff on another resident, again failing to clean it afterward. This practice was contrary to the facility's policy, which requires the cleaning and disinfection of reusable resident care equipment between each use according to CDC recommendations and OSHA standards. In an interview, MA G expressed a misunderstanding of the facility's policy, believing that the blood pressure cuff only needed to be cleaned after every two residents. The Director of Nursing (DON) confirmed that the staff should sanitize the blood pressure cuff between each resident to prevent infections. The facility's policy, dated March 1, 2022, clearly states that reusable resident care equipment must be decontaminated and/or sterilized between residents according to the manufacturer's instructions, highlighting a lapse in adherence to established infection control protocols.
Failure to Ensure Visual Privacy for Resident
Penalty
Summary
The facility failed to ensure full visual privacy for a resident in one of the rooms reviewed. During an observation, a resident was seen lying on their side in bed with their back and buttocks exposed and visible from the hallway. This occurred while a staff member was holding the resident on their side, and another staff member was standing in the doorway, with a treatment nurse in the hallway. The lack of a privacy curtain in the resident's room contributed to this exposure. Interviews with staff members revealed that there was no privacy curtain installed in the resident's room, and it was acknowledged that nursing staff and maintenance were aware of this absence. The staff typically provided privacy by closing the door, but in this instance, the door was left open while waiting for wound care to be administered. The Director of Nursing confirmed that being visible from the hallway did not provide privacy, aligning with the resident's rights to dignity and respect.
Medication Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A medication aide (MA) administered incorrect medications, Seroquel 50 mg PO and Ativan 0.5 mg PO, to a resident who did not have orders for these medications. The error occurred because the MA did not correctly identify the resident before administering the medications. The MA entered the resident's room, asked for the resident's name, and proceeded with the administration without proper verification, despite the presence of the resident's responsible party (RP) who neither corrected nor verified the MA's question. The resident involved had a medical history of chronic respiratory failure, type 2 diabetes, and hypertension. The facility's policy on administering medications requires verification of the resident's identity through methods such as checking an identification band, a photograph attached to the medical record, calling the resident by name, or verifying with other facility personnel. However, these procedures were not followed, leading to the medication error.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in the bedroom of a resident, which is a critical requirement for resident safety and communication. During an observation, it was noted that the call button in the resident's room was not functioning and had exposed wires. This deficiency was confirmed by a Licensed Vocational Nurse (LVN) who verified that the call light was not operational, acknowledging the potential risk of harm to the resident, including injury, pain, or hospitalization. The resident involved was a 94-year-old male with a history of dementia, atherosclerosis, and a cerebral ischemic attack. He was moderately cognitively impaired, as indicated by a BIMS score of 09, and was dependent on staff for activities of daily living (ADLs) due to incontinence. The maintenance director later identified that the call light wires were not connected, which was the cause of the malfunction. The facility's policy on answering call lights, dated June 2012, requires that call lights be plugged in at all times and that any defects be reported promptly to the Nurse Supervisor.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #1 was seen by a physician at least once every 60 days after the initial 90 days following admission. Resident #1, who was admitted with diagnoses including unspecified dementia, generalized anxiety disorder, and muscle weakness, had a significant gap of 188 days between physician visits. The resident was last seen by Physician C on 9/29/23 and was not seen again until 4/2/24. This gap in care was confirmed through record reviews and interviews with Resident #1's family member and Physician C. During interviews, the Director of Nursing (DON) was unable to recall the facility's policy on the frequency of physician visits and acknowledged that a process to ensure regular physician visits was in progress. The facility's policy, dated April 2008, mandates that attending physicians must visit their patients at least once every 30 days for the first 90 days following admission and at least every 60 days thereafter. The failure to adhere to this policy could lead to adverse effects on residents' health, as noted by the DON.
Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments. Agency LVN A left the 100 Hall medication cart unlocked and unattended while answering a call light in another hall. During an interview, Agency LVN A acknowledged that the medication cart should have been locked and stated she was educated on medication security during her orientation. The Director of Nursing (DON) confirmed that medication carts should be locked when not in use and mentioned that the DON, ADON, medical records, and the treatment nurse conduct hourly rounds to check if medication carts are locked. The facility's policy on the storage of medications, dated April 2007, requires that compartments containing drugs and biologicals be locked when not in use.
Expired Eyewash Solution in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a bottle of eyewash solution above the handwashing sink in the kitchen was found to be expired. During an observation and interview, Cook B confirmed the eyewash solution was expired and admitted to not knowing how frequently the eyewash solution was checked. A review of the facility's policy on the storage of medications revealed that the facility should not use discontinued, outdated, or deteriorated drugs or biologicals.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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