Harmony Care At Beaumont
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, Texas.
- Location
- 2660 Brickyard Rd, Beaumont, Texas 77703
- CMS Provider Number
- 675595
- Inspections on file
- 52
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 33 (5 serious)
Citation history
Health deficiencies cited at Harmony Care At Beaumont during CMS and state inspections, most recent first.
A cognitively impaired male resident with dementia and Alzheimer’s disease, assessed as severely impaired and rarely understood, was allegedly physically abused by a CNA during incontinence care after refusing care. Another CNA reported that the CNA forcibly pushed the resident onto the bed, manhandled him, hit his arms multiple times with a closed fist, pinned his hands, forcibly removed his shorts and brief, and then allowed him to walk out of the room with his lower body uncovered despite objections. The resident later showed no skin injury and could not recall the incident, while the alleged perpetrator denied the abuse and the reporting CNA and a family member confirmed and acted on the allegations.
Nursing and medication staff failed to consistently sign controlled drug count sheets at the start and end of their shifts, despite facility policy requiring shift-to-shift counting and documentation of controlled substances. Review of controlled drug records over several months showed multiple missing signatures by several LVNs and a medication aide on various halls and shifts, even though some staff reported they had performed the counts but forgot to sign. Leadership acknowledged that all nurses and MAs were responsible for signing the controlled drug sheets and that oversight of these records had been missed, and the report states this failure could place the facility at risk for drug diversion.
Multiple residents experienced abuse and neglect, including unwanted sexual contact, physical and verbal abuse by staff, and repeated resident-to-resident altercations. Incidents involved individuals with significant cognitive and behavioral impairments, and staff failed to intervene effectively to prevent or stop the abuse, despite known risks and documented behavioral histories.
The facility did not update or implement comprehensive care plans for several residents following incidents of aggression and inappropriate sexual behavior. After a male resident inappropriately touched a female resident, his care plan lacked new interventions to prevent further episodes. Similarly, care plans for residents involved in multiple altercations were not revised to address their evolving needs, and there was no effective system to ensure care plan updates were completed after such incidents.
Staff failed to immediately report multiple incidents of alleged abuse and resident-to-resident altercations to the abuse coordinator and state authorities as required. In one case, a staff member witnessed a CNA verbally and physically abuse a resident with cognitive impairments but delayed reporting the incident. In other cases, a nurse did not promptly report a physical altercation between two residents, and another incident involving a resident being scratched and injured was not reported to the administrator until the following day. These lapses resulted in delayed investigations and placed residents at risk.
Multiple rooms were found with dead cockroaches, missing baseboards, stained flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Several residents reported that while their rooms were cleaned, bathrooms were not properly maintained and pest issues persisted. Facility staff, including the Administrator and Maintenance Director, were unaware of these issues, and no maintenance requests had been logged for the observed deficiencies. The Housekeeping Supervisor acknowledged inadequate cleaning practices and the absence of a cleaning checklist.
Two CNAs failed to follow hand hygiene protocols while providing incontinent care to a resident with diabetes, severe obesity, and moderate cognitive impairment. After cleaning the resident, the CNAs did not perform hand hygiene when changing gloves or moving from dirty to clean tasks, only sanitizing their hands after care was completed. Interviews indicated inconsistent understanding and training regarding hand hygiene requirements, despite facility policies and in-services outlining these procedures.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple complex diagnoses, including quadriplegia, diabetes, and depression, did not have several active conditions accurately documented in the MDS assessment. Staff interviews revealed confusion over responsibility for MDS accuracy, absence of a current MDS Coordinator, and lack of a specific MDS policy, resulting in incomplete assessment of the resident's health status.
Persistent foul odors were present in a hallway and several rooms due to some residents refusing hygiene care, despite repeated cleaning by housekeeping staff. Additionally, a resident's dresser remained in disrepair for months, with broken and missing handles and drawers that would not close, causing frustration for the resident. These issues resulted in an environment that was not consistently clean, comfortable, or homelike.
Surveyors observed live and dead cockroaches and spiders in multiple resident rooms, including pests on furniture and food trays. Several residents reported feeling distressed by the presence of pests. Staff and maintenance confirmed periodic pest sightings and documented ongoing issues in facility logs, despite regular pest control treatments and reporting procedures.
A resident with a history of mental health conditions expressed grievances about specific CNAs providing her care, citing improper care and feeling unsafe. Despite being cognitively intact and able to communicate her needs, the facility failed to adequately address her concerns, as the CNAs continued to be assigned to her. The facility's grievance policy was not followed, leading to unresolved issues and potential decreased quality of life for the resident.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. Interviews and record reviews revealed staffing challenges, including difficulties in hiring RNs and ensuring consistent coverage. The facility's policy requires an RN to be onsite for 8 consecutive hours daily, which was not consistently met.
The facility failed to submit complete and accurate direct care staffing information to CMS for two quarters in 2024. This was due to oversight and confusion about responsibilities among staff, with the Regional Director of Clinical Operations and Corporate HR unaware of the need to ensure timely submission. The facility's policy on reporting staffing information was not followed, leading to the deficiency.
The facility failed to maintain essential equipment safely, including a gas stove with non-igniting burners, a walk-in freezer with a loose gasket, and a milk box with mildew. Additionally, an electric bed in a resident's room had a spliced electrical cord with exposed live wires. The issues were not reported by staff, and the facility's Maintenance Service policy was not followed.
The facility failed to maintain a safe and sanitary environment, with issues in Hall 200, the dining room, and specific resident rooms. Observations showed discolored tiles, missing paint on door frames, and a buildup of debris. An unlocked closet labeled for oxygen storage was found with black fuzzy substance and spider webs. Interviews with staff confirmed awareness of these issues, but no documented plans for repairs were in place.
The facility's kitchen had unsanitary conditions, with baking sheets and pans showing buildup, improperly labeled and expired food items, and inadequate sanitizing solution. These issues could risk foodborne illness among residents.
A facility failed to properly store medications, leaving a resident's nystatin powder unsecured on a bedside table. The resident, who was cognitively intact and had diabetes, was unaware of the powder's presence. Interviews with the ADON and Administrator confirmed that medications should not be left in resident rooms and should be stored in the medication cart when not in use.
Two residents with cognitive impairments were involved in a sexual abuse incident in the dining room, highlighting a failure in the facility's protective measures. Despite having care plans addressing inappropriate sexual behaviors, the incident occurred, indicating a lapse in intervention implementation.
The facility failed to report abuse allegations involving four residents to the State Agency within the required 2-hour timeframe. In one case, a resident with cognitive impairment assaulted another resident, and in another, a resident with mental health issues attacked a fellow resident. Both incidents were documented, but the reports were delayed, violating the facility's policy for immediate notification.
A facility failed to implement the PASRR comprehensive service plan for a resident with schizoaffective disorder, cerebral palsy, dysphagia, and aphasia. The resident was identified as PASRR positive for intellectual disability, and the plan recommended specialized therapies. However, these services were not provided within the required timeframe due to authorization issues, delaying the initiation of therapy services. The facility did not meet PASRR requirements for timely service initiation, as confirmed by the Regional Director of Reimbursement.
A resident with dementia and a history of inappropriate sexual behavior was involved in two incidents of touching female residents' breasts. Despite interventions, the facility failed to ensure adequate monitoring and documentation, leading to an Immediate Jeopardy situation. Staff interviews revealed inconsistencies in awareness and reporting, highlighting deficiencies in the facility's abuse prevention policy.
A resident with a history of inappropriate sexual behavior was not adequately monitored, leading to incidents of inappropriate touching of two other residents. The facility failed to implement its policies for preventing abuse, neglect, and exploitation, resulting in a deficiency. Staff did not maintain one-on-one monitoring or update care plans, despite the resident's known behaviors.
The facility failed to maintain a full-time DON and consistent RN coverage, lacking a DON from mid-August to late September and missing RN coverage on several days in September. The Administrator was unaware of the option to use agency nurses for RN coverage, and the facility lacked a policy for ensuring proper staffing.
A facility failed to limit PRN orders for psychotropic drugs to 14 days without proper documentation, affecting three residents. One resident with dementia and delusional disorder received Ativan without a stop date or behavior monitoring. Another resident with schizoaffective disorder received PRN Ativan injections without a pharmacy review. A third resident with dementia and anxiety received Lorazepam without a stop date. Staff interviews revealed a lack of awareness of the 14-day requirement and inadequate monitoring of behaviors and side effects.
A facility failed to report allegations of sexual abuse involving a resident with dementia who inappropriately touched two female residents on separate occasions. Despite the facility's policy requiring immediate reporting, the incidents were not reported to the state agency, potentially placing residents at risk. Staff interviews revealed a lack of clarity and communication regarding the reporting process.
The facility failed to address significant weight loss and nutritional needs for five residents, leading to severe weight loss without appropriate dietary interventions. Despite care plans and dietician recommendations, there was a lack of communication and implementation of necessary dietary changes, resulting in unaddressed weight loss and potential health decline.
A resident with a PICC line did not have their dressing changed as ordered, and a treatment nurse failed to follow proper hand hygiene protocols during wound care. The facility's infection control policies were not adhered to, leading to potential infection risks.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, including cellulitis and diabetes. The absence of this care plan was confirmed through record reviews and staff interviews, highlighting a lapse in following the facility's policy, which mandates such plans to ensure immediate care needs are met.
A facility failed to maintain and revise a resident's care plan after it was mistakenly closed, despite the resident not being discharged. The resident, with multiple health conditions and severe cognitive impairment, did not have their care plan updated quarterly as required. Interviews revealed that the MDS Coordinator and DON were responsible for ensuring care plans were active and revised, but this was not done due to the error.
A resident with multiple diagnoses, including functional quadriplegia, did not receive appropriate contracture management at the facility. Despite severe flexed contractures and decreased ROM noted in an OT assessment, the resident was discharged from OT services without recommendations for a hand roll or positioning device due to lack of a payer source. Facility staff were unaware of the need for contracture management, and there was no documentation or care plan addressing the resident's condition, contrary to the facility's policies on joint mobility and rehabilitative nursing care.
A resident with schizophrenia was improperly discharged from an LTC facility before the end of a 30-day notice period. After being treated at a behavioral hospital, the facility refused to readmit her, citing safety concerns and lack of space. The resident was left at a local hospital, displaying no aggressive behaviors, while the facility had already given her bed to another resident.
A facility failed to follow its policy on readmitting a resident after hospitalization, leading to a deficiency. The resident, with a history of schizophrenia and mood disorder, was not allowed to return before the 30-day discharge notice period ended. The facility cited safety concerns and lack of space, despite the resident being discharged from a behavioral hospital. Staff were instructed not to readmit the resident, who was eventually taken to another hospital.
A resident in a long-term care facility expressed a grievance about a CNA, feeling unsafe and afraid, but the grievance was not documented or reported as required. Despite the resident's cognitive intactness, the grievance was not addressed by the staff, including a CMA and the CNA involved. The facility's policy mandates that grievances be documented and forwarded to the Grievance Official, but this was not done, resulting in a deficiency.
A resident with severe cognitive impairment and aggressive behaviors did not have a comprehensive care plan addressing these issues. Despite documented aggression, the facility failed to implement a care plan, leading to incidents where staff were physically attacked. Interviews revealed the omission was a mistake, highlighting the need for adherence to care planning policies.
The facility failed to conduct weekly skin assessments for three residents, as required by their care plans, due to a lack of scheduling and notification in the electronic record system. This oversight, involving residents with conditions like dementia, cellulitis, and hemiplegia, was identified through interviews and record reviews, revealing a risk of inadequate care and medical interventions.
A resident with severe cognitive impairment and a care plan requiring nail trimming was found with long, jagged fingernails, indicating a failure in maintaining personal hygiene. Staff interviews revealed a lack of awareness and documentation regarding the resident's nail care, with the DON unable to locate care sheets and the Administrator expecting staff to keep nails trimmed to prevent skin issues.
The facility failed to immediately notify the physician and responsible party after a resident placed a pillow over another resident's face, leading to a delay in medical intervention and potential harm.
The facility failed to protect two residents from abuse, including one incident where a resident was pulled out of her wheelchair and another where a resident placed a pillow over her roommate's face with intent to harm. There were delays in reporting, inadequate documentation, and insufficient immediate corrective actions.
A resident with schizophrenia and moderate cognitive impairment was involved in two aggressive incidents, including attempting to suffocate her roommate. The facility failed to implement immediate one-on-one supervision or other safety measures, and staff did not document the incidents properly or notify the necessary parties in a timely manner.
The facility failed to update comprehensive person-centered care plans for three residents after significant incidents of physical aggression. The MDS nurse was unaware of these incidents, leading to care plans not being revised to reflect the changes in resident behavior and needs.
A male resident with complex medical conditions including diabetes, heart failure, and respiratory failure was found unresponsive, not breathing, and without a pulse. Despite being a full code with physician orders for CPR, the staff did not use the AED during resuscitation efforts. The LVN who initiated CPR did not call for the AED, citing being preoccupied with CPR. The DON confirmed the AED was not used and noted it should have been called for along with the crash cart. Observations revealed the AED was located down the hall from the crash cart, and the facility's crash cart checklists did not include an AED inspection.
Failure to Protect Cognitively Impaired Resident From Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident was an elderly male with dementia, anxiety disorder, and Alzheimer’s disease, admitted in February and assessed as severely cognitively impaired with a BIMS score of 3.0 and rarely/never understood. His care plan identified impaired cognition and risk for further decline and injury. Despite these vulnerabilities, the resident was subjected to alleged physical abuse during care provision by a CNA. According to a written statement from another CNA who was present, the incident occurred when the two CNAs attempted to provide incontinence care and the resident refused. After the resident refused care multiple times, the reporting CNA began to leave the room, at which point the other CNA allegedly tried to force the resident onto the bed. The resident became somewhat aggressive, and the CNA allegedly responded by manhandling him, forcing him into the bed, and, when the resident tried to push him away, hitting the resident on the arms approximately three to four times with a closed fist. The CNA then allegedly pinned both of the resident’s hands down, forcibly pulled down his shorts, and ripped off his brief, leaving him lying on the bed with his bottom uncovered. The reporting CNA stated she repeatedly told the other CNA to leave the resident alone and to report the situation, but he refused. When the CNA realized the resident would not allow him to complete the change, he allowed the resident to get up and walk out of the room with no clothing on his lower body. The reporting CNA attempted to stop the resident from leaving the room without pants, but the resident did not allow her to do so. The resident was later assessed multiple times with no skin injuries noted, and he was unable to recall any issues with staff during interview attempts. The alleged perpetrating CNA denied being rough or abusive, while the reporting CNA confirmed her written account during a subsequent phone interview. The resident’s family member later stated she filed charges against the CNA and described being extremely upset and traumatized by the incident.
Incomplete Controlled Drug Count Documentation by Nursing and Medication Staff
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate controlled drug count records and to ensure that all staff responsible for controlled medications signed the controlled drug count sheets as required. Review of controlled drug count sheets for multiple halls and shifts in January and February showed missing signatures from several LVNs and a medication aide on dates and shifts when they had responsibility for the medication carts. The controlled drug count forms stated that signing acknowledges the staff member has counted the controlled drugs on hand and verified that the quantity matches the Controlled Drug Administration Record, but these signatures were absent on numerous shifts across different halls. Interviews with involved nursing staff confirmed that they understood they were responsible for signing the controlled drug sheets at the beginning and end of their shifts to document that they had counted and assumed responsibility for the controlled medications. One LVN stated she had counted the controlled medications on the identified dates but could not recall why she did not sign the sheets, acknowledging that she had been trained to sign when coming on and leaving her shift. Another LVN reported that she had counted the drugs on the listed dates and attributed the missing signatures to forgetting after working double shifts, while stating that her narcotic counts had always been accurate. A third LVN similarly stated she always counted the controlled medications before taking responsibility for them but could not recall why she did not sign on the specified dates. Additional attempts to interview a medication aide and another LVN involved were unsuccessful. The DON stated that nurses and MAs were expected to sign in and out on the controlled drug sheets to ensure controlled drugs were being counted accurately and acknowledged that she and the ADON were responsible for reviewing the sheets twice weekly, but that the sheets had been overlooked while she was adjusting to her role. The Administrator also stated that all nurses and MAs were responsible for signing in and out on the controlled drug count sheets. The facility’s written policy on controlled substances required nursing staff to count controlled medications at the end of each shift, with the oncoming and offgoing nurses counting together and documenting the count, and using these records to reconcile inventory and identify loss or potential diversion. The report notes that this failure could place the facility at risk for drug diversion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both staff-to-resident and resident-to-resident abuse. In one instance, a female resident with a history of cerebral infarction, schizophrenia, and hemiplegia was subjected to unwanted sexual contact by another resident, who entered her room and rubbed her leg under the covers without consent. The incident was witnessed by a hospice RN, and the resident expressed that she was upset by the event. The perpetrator had a documented history of inappropriate sexual behaviors and was cognitively intact at the time of the incident. There were also multiple cases of physical and verbal abuse perpetrated by staff members against a male resident with traumatic brain injury, dementia, and severe cognitive impairment. One CNA was observed by another staff member to have called the resident derogatory names, physically restrained him during care, and used excessive force, including pinning him against a wall and stomping on his feet. Another CNA was reported to have verbally abused the same resident and forcefully pushed him into a chair. Both incidents were substantiated by witness statements and resulted in the termination of the staff involved. Additionally, the facility failed to prevent and appropriately manage numerous resident-to-resident altercations, resulting in physical harm such as scratches, hitting, and other aggressive behaviors. These incidents involved residents with significant cognitive and behavioral impairments, including dementia, bipolar disorder, and psychotic disorders. The care plans for these residents indicated known risks for aggression and behavioral issues, yet the facility did not effectively intervene to prevent repeated episodes of abuse among residents.
Failure to Update and Implement Comprehensive Care Plans After Resident-to-Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following incidents of resident-to-resident aggression and inappropriate sexual behavior. In several cases, care plans were not updated to reflect new or recurring behavioral incidents, nor were interventions added to prevent further occurrences. For example, after an incident where a male resident inappropriately touched a female resident, the care plan for the perpetrator did not include specific interventions to prevent further sexual abuse episodes, despite documentation of the event and its investigation. Additionally, care plans for residents who were either aggressors or victims in multiple resident-to-resident altercations were not revised to address their changing needs. One resident with a history of physical aggression was involved in several incidents with other residents, resulting in scratches, skin tears, and emotional distress. Despite these events, the care plans for both the aggressor and the victims were not promptly or adequately updated to include new interventions or strategies to mitigate future risks or address the impact of the incidents. The deficiency was further compounded by a lack of verification and follow-through in the care plan update process. The administrator acknowledged that while requests to update care plans were communicated via email to the MDS contractor, there was no system in place to ensure these updates were completed. This breakdown in communication and oversight resulted in care plans that did not accurately reflect the residents' current needs or the interventions required to ensure their safety and well-being, as evidenced by repeated incidents and confirmed findings in the facility's own investigations.
Removal Plan
- Resident #1's care plan was updated; psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening.
- Resident #2, #3 and #5 care plans updated regarding receiving abuse
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator and within the required two-hour timeframe to the administrator and state authorities. In one instance, a staff member witnessed a certified nursing assistant verbally and physically abuse a male resident with traumatic brain injury, dementia, and other cognitive impairments. The staff member did not report the incident immediately, only disclosing it during an unrelated investigation approximately 1.5 weeks later. The abuse coordinator became aware of the incident during staff interviews, and the administrator did not report the new allegation to the state as a separate event. In another case, a licensed vocational nurse failed to report an allegation of abuse involving two residents engaged in a physical altercation. The nurse documented the incident but did not notify the administrator or director of nursing as required. The director of nursing only became aware of the incident upon reviewing progress notes the following day. The nurse involved stated she was not present during the incident and did not recall being trained to report abuse immediately to the administrator. A third incident involved a delay in reporting a resident-to-resident altercation where one resident scratched and pulled another resident's hair, resulting in a visible injury. The administrator was not informed of the incident until the following day, after the resident reported it and showed the injury. The administrator acknowledged that the allegation was reported late and that all abuse allegations are required to be reported to state agencies within two hours of the incident. These failures were identified through observations, interviews, and record reviews, and were found to place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Maintain Clean, Safe, and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, functional, and comfortable environment for residents in several rooms, as evidenced by the presence of dead bug carcasses and dead cockroaches in resident bathrooms and vanities. Observations revealed missing baseboards, stained caulk and flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Multiple residents confirmed that while housekeeping staff cleaned their rooms, the bathrooms were not cleaned properly, and dead cockroaches were not removed. Residents also reported that the bathroom tiles had been falling off for some time. Interviews with facility staff, including the Administrator, Maintenance Director, and Housekeeping Supervisor, revealed a lack of awareness regarding the physical plant issues and the presence of pests. The Maintenance Director and Administrator both acknowledged the observed deficiencies during walkthroughs but stated they had not received any maintenance requests for the repairs. The Housekeeping Supervisor admitted that bathrooms and vanities were not cleaned as thoroughly as required and that there was no cleaning checklist or follow-up to ensure proper cleaning. Staff indicated that maintenance requests were supposed to be logged at the nurse station, but no such requests had been made for the observed issues. A review of facility policies indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards, and that staff are expected to provide a clean, sanitary, and homelike environment. Despite these policies, the observed conditions in the resident rooms and bathrooms did not meet these standards, as evidenced by the lack of cleanliness, unrepaired damage, and unaddressed pest issues.
Failure to Maintain Proper Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to proper hand hygiene protocols while providing incontinent care to a resident with multiple comorbidities, including diabetes mellitus type 2, severe obesity, and moderate cognitive impairment. During the observed care, both CNAs wore gowns and gloves, but after cleaning the resident, one CNA did not perform hand hygiene after changing gloves or when transitioning from dirty to clean supplies. The other CNA, after removing a soiled brief and cleaning the resident, touched clean linens and adjusted a clean brief without changing gloves or performing hand hygiene. Both CNAs only completed hand hygiene after the care was finished and gloves were removed. Interviews revealed that one CNA acknowledged the need for hand hygiene after glove changes and when moving from dirty to clean, as trained by the facility, but apologized for not having hand sanitizer available during care. The other CNA was unclear about the specific requirements for hand hygiene after glove changes or when moving from dirty to clean, stating she was not trained in those aspects. The Director of Nursing confirmed that infection control in-services were conducted regularly and that staff were expected to follow the hand hygiene policy, which requires hand hygiene before and after resident contact, between glove changes, and after soiled hands. Facility policy and recent in-service documentation supported these requirements.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Accurately Complete MDS Assessment for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their current status, specifically regarding the completion of the Minimum Data Set (MDS) assessment. Record review showed that the resident, a male with multiple complex diagnoses including quadriplegia, diabetes, chronic kidney disease, neurogenic bladder, and major depressive disorder, had an MDS assessment that did not include several of his active diagnoses such as coronary artery disease, neurogenic bladder, quadriplegia, or depression. The resident was cognitively intact, used a wheelchair, and was dependent for most activities of daily living (ADLs). Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for the accuracy and completion of the MDS. The DON stated that although her signature appeared on the MDS, she could not verify it and was not informed she should review the MDS for accuracy. The Administrator and VPO both indicated that the facility did not have a current MDS Coordinator at the time, and that oversight was expected from either the DON or a Regional MDS Coordinator, who had also recently been terminated. The facility did not have a specific MDS policy and relied on the RAI manual. This lack of accurate assessment and clear responsibility could result in residents not receiving appropriate care and services.
Failure to Maintain Sanitary Environment and Functional Resident Furnishings
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents in rooms 217 through 224, as evidenced by persistent foul odors in the hallway and in front of specific rooms. Observations revealed a strong smell of urine, feces, and body odor throughout the hallway, with the odor being most pronounced in front of one room. The odor was present at multiple times during the day, despite the presence of housekeeping staff and repeated cleaning efforts. Interviews with staff and residents confirmed that some residents refused hygiene care and bathing, contributing to the ongoing odor issue. Housekeeping staff reported cleaning certain rooms multiple times daily and using specific chemicals to address the odor, but the problem persisted, particularly in rooms where residents refused showers. Additionally, a dresser in one resident's room was found to be in disrepair, with multiple broken or missing handles and drawers that would not close properly. The resident reported that the dresser had been broken for several months and expressed frustration about the situation. The Maintenance Director stated that maintenance issues were addressed as reported, but there was no record of the broken dresser being reported. The administrator confirmed that a replacement dresser had been ordered but had not yet arrived, resulting in the continued use of the damaged furniture. These deficiencies were observed to negatively impact the quality of life and comfort of the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in multiple resident rooms being infested with cockroaches and spiders. Observations by surveyors revealed live and dead cockroaches in several rooms, including instances where cockroaches were seen running across furniture, breakfast trays, and restroom sinks. Spiders, both live and dead, were also found in resident rooms. Residents expressed distress about the presence of pests, with one resident stating that the cockroaches made her feel terrible and another reporting roaches on her breakfast tray. Staff interviews confirmed that pests were seen occasionally, with sightings of flies and cockroaches occurring a couple of times a month. The facility maintained a pest control log and had a contract with a pest control company to spray monthly and as needed, with additional treatments in certain months. Staff were instructed to report pest sightings in a binder at the nurses' station, and plastic containers were provided to residents who kept food in their rooms to help limit pest issues. Despite these measures, maintenance records and pest control logs documented ongoing reports of roaches in specific rooms over the preceding months. The facility's policy required maintaining an effective pest control program to keep the building free of insects and rodents, but observations and records indicated that this standard was not met for several residents.
Failure to Resolve Resident Grievances Regarding CNA Assignments
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who expressed dissatisfaction with certain CNAs providing her care. The resident, who was cognitively intact and able to communicate her needs, had a history of mental health conditions including dementia, anxiety, schizophrenia, and bipolar disorder. She repeatedly voiced grievances about not wanting specific CNAs, identified as CNA A and CNA B, to enter her room or provide care, citing reasons such as improper care and feeling unsafe. Despite the resident's grievances being documented, the facility did not take adequate action to address her concerns. The grievances were not thoroughly investigated, and there was a lack of communication among staff regarding the resident's preferences. The facility's staffing sheets indicated that CNA A and CNA B continued to be assigned to the resident on multiple occasions, contrary to her expressed wishes. Interviews with staff revealed a lack of awareness and communication about the resident's grievances, with some staff members unaware of the resident's requests or the grievances filed. The facility's grievance policy required immediate action to resolve complaints, but this was not adhered to in the case of the resident. The failure to address the resident's grievances could lead to unresolved issues and a decreased quality of life for the resident. The facility's leadership, including the DON and the grievance official, were not fully informed or proactive in resolving the resident's concerns, resulting in continued dissatisfaction and anxiety for the resident.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that there were no RN hours recorded on several specific dates, and on some days, the RN hours were less than the required 8 hours. The facility's records indicated that there were 4 RNs employed, but the facility struggled with staffing issues, including hiring a Director of Nursing (DON) and ensuring consistent RN coverage. Interviews with the Human Resources representative, the DON, and the Administrator highlighted the staffing challenges faced by the facility. The HR representative acknowledged the missing RN hours and the difficulty in hiring RNs. The DON, who started in November, confirmed the lack of sufficient staff to provide the required RN coverage before her tenure and emphasized the importance of adhering to the policy. The Administrator also acknowledged the staffing issues and the potential impact on resident care due to inadequate RN coverage. The facility's policy mandates that an RN must be onsite for 8 consecutive hours daily, which was not consistently met during the review period.
Failure to Submit Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for two of the three quarters reviewed, specifically for Quarter 2 and Quarter 3 of 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility did not submit the required Payroll-Based Journal (PBJ) reports for these periods. The failure to submit these reports was attributed to a lack of oversight and responsibility confusion among the staff. The Regional Director of Clinical Operations was identified as the person responsible for submitting the PBJ reports, but it was discovered that a third-party company previously tasked with this responsibility had not been submitting the reports, leading to the termination of their contract. Interviews with various staff members, including the HR, the Regional Director of Clinical Operations, the Director of Nursing (DON), the Administrator, and the Corporate HR, highlighted a lack of awareness and education regarding the submission process. The HR mentioned that the staff clock in and out, and the system logs the times, but the PBJ reports were not submitted due to oversight. The Regional Director of Clinical Operations and the Corporate HR both acknowledged that they were not aware of the need to check if the reports were submitted. The facility's policy on reporting direct-care staffing information was not followed, resulting in the failure to submit the PBJ reports timely, which could affect the facility's ability to take credit for the staff present and potentially impact the quality of care provided.
Facility Fails to Maintain Safe Operating Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed during a survey. The gas stove in the kitchen had three burners that would not ignite, and there was a black buildup on the griddle next to the burners. The walk-in freezer had a loose and hanging door gasket, with icy frost and frozen liquid on the floor. Additionally, the milk box had a loose gasket with mildew. These issues were acknowledged by the Dietary Manager (DM) and Maintenance Director (MD), who were unaware of the severity of the problems. In a resident's room, an electric bed was found with a spliced electrical cord, exposing live wires without proper insulation or a connection box. The Administrator expressed that the electric beds should be in good working condition and noted that staff had not reported the unsafe wiring. The facility's Maintenance Service policy indicates that the Maintenance Department is responsible for ensuring all equipment is safe and operable, which was not adhered to in these instances.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several areas, including Hall 200, the dining room, and specific resident rooms. Observations revealed that door frames in Hall 200 were not intact, with missing paint and wood pieces, and the floor tiles were discolored with a buildup of glue, paint, and debris. The exit corridor to the smoking area had six missing floor tiles, exposing discolored concrete. In the main dining room, there was a buildup of old paint and dried glue along the back wall, and a missing tile near the door created a floor level difference. An unlocked closet labeled for oxygen storage was found empty, with walls covered in a black fuzzy substance, a white substance on the door, and spider webs with sacs, emitting a smell of wet dirt. Additionally, specific resident rooms were not properly maintained. One room had a 6-inch base trim detached from the wall and lying on the floor for approximately 5 feet. Another room had a beige substance splattered on the ceiling and curtains with rips along the bottom. Interviews with the maintenance director and the administrator revealed acknowledgment of these issues, with the maintenance director admitting to never opening the problematic closet and the administrator confirming the need for repairs but lacking documented plans for such actions. The facility's maintenance service policy indicated that the maintenance department is responsible for keeping the building safe and operable at all times.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Baking sheets, pans, and skillets were found with dark-colored buildup on both the inside and outside surfaces, indicating they were not properly cleaned. Additionally, food items in the walk-in cooler were not managed according to professional standards. A container of pureed food was found with an unreadable label and was past its use-by date, while another container of fruit lacked any labeling. These lapses in food storage and labeling could potentially lead to foodborne illnesses among residents. Furthermore, the facility did not ensure that the sanitizing solution used for cleaning kitchen surfaces was at the correct concentration. A red bucket of sanitizing solution was found to have less than 50 ppm of chlorine, indicating it was ineffective. The chlorine solution container was not connected to the dispenser, which is used to fill the sanitizing bucket. These deficiencies were in violation of the facility's own policies and the 2022 Food Code, which require proper labeling, cleaning, and sanitizing practices to prevent contamination and ensure food safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication, specifically affecting one resident. During an observation, a 30-cc medicine cup containing approximately 20 cc of white powder was found on the nightside table next to the resident's bed. The resident, who was cognitively intact and had diabetes, stated that the powder was not her medication and was unaware of how it got there. The powder was identified as nystatin powder, which was prescribed to be applied to the resident's abdominal folds for yeast treatment. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the medication should not have been left in the resident's room and should have been stored in the medication cart when not in use. The ADON confirmed that nurses were responsible for ensuring medications and treatment items were not left in resident rooms. The Administrator stated that her expectation was for nurses to keep medications within their eyesight and not leave them at the bedside, indicating a lapse in following proper medication storage protocols.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure the safety and protection of two residents from sexual abuse. On June 15, 2024, an incident occurred in the dining room where one resident, who has moderate intellectual disabilities and is non-verbal, was observed performing oral sex on another resident. The first resident has a history of inappropriate sexual behaviors and is severely cognitively impaired, as indicated by a BIMS score of 03. The second resident, who has a BIMS score of 10 indicating moderate cognitive impairment, did not exhibit any behaviors over the previous seven days. Both residents were known to have inappropriate sexual behaviors and were at risk for further episodes. The incident was witnessed by another resident, who reported it to the staff. The staff responded by separating the involved residents and notifying the appropriate authorities, including the police. The second resident, who was on parole, was noted to have been in a motorized wheelchair and did not attempt to remove himself from the situation. The police were involved, and statements were taken from the residents involved. The facility's records indicate that the second resident was aware of the incident and expressed a desire to have it documented by the police. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as both residents involved had documented histories of inappropriate sexual behavior. The facility's care plans for both residents included interventions to manage these behaviors, but the incident still occurred, indicating a lapse in the implementation of these interventions. The facility's policy on abuse and neglect emphasizes the importance of preventing such incidents, but the occurrence of this event suggests that the policy was not effectively enforced at the time.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the required 2-hour timeframe for four residents. In the first incident, Resident #4, who has a history of behavioral issues and cognitive impairment, verbally and physically assaulted Resident #5. Despite the incident being documented by an LVN, the facility did not notify the State Agency within the mandated period. Resident #4 was later transferred to a behavioral center for further management of his behavior. In the second incident, Resident #6, who suffers from severe cognitive impairment and mental health issues, physically assaulted Resident #7 after a minor altercation involving a wheelchair. The incident was documented, and both residents were assessed for injuries, but the report to the State Agency was delayed beyond the required 2-hour window. Resident #6 was subsequently transferred to a behavioral hospital for further evaluation and treatment. Interviews with facility staff, including the ADON and the Administrator, revealed that there was a lack of immediate reporting to the Abuse Coordinator, which contributed to the delay in notifying the State Agency. The facility's policy mandates immediate reporting of abuse allegations to the Administrator or their designee, but this protocol was not followed, resulting in the deficiency.
Failure to Implement PASRR Service Plan for Resident
Penalty
Summary
The facility failed to implement the PASRR comprehensive service plan for a resident who was reviewed for PASRR assessments. The resident, a male with diagnoses including schizoaffective disorder, cerebral palsy, dysphagia, and aphasia, was admitted to the facility and was identified as PASRR positive for intellectual disability. The PASRR Comprehensive Service Plan recommended specialized occupational therapy, physical therapy, and speech therapy, which were not provided within the required timeframe. The Director of Rehabilitation indicated that therapy evaluations were submitted but not authorized, resulting in a delay in the initiation of therapy services. The Regional Director of Reimbursement confirmed that the facility did not meet the PASRR requirements, which mandate that specialized services be requested and initiated within specific timeframes. The resident did not receive the agreed-upon therapy services through PASRR until several months after the initial PCSP and IDT meeting. The Administrator, who was not present during the initial meeting, acknowledged the potential negative outcomes of not meeting PASRR timeframes. The facility's policy indicated that they should coordinate services per state policy and develop a care plan addressing specific needs when special services are required.
Failure to Protect Residents from Abuse Due to Inadequate Monitoring and Reporting
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving inappropriate sexual behavior by a resident with dementia and other mental health conditions. The resident, who had a history of inappropriate sexual behaviors, was involved in two incidents where he touched the breasts of two different female residents. The first incident occurred in the dining room, where the resident grabbed another resident's breast and made lewd comments. Despite being redirected and sent for a psychiatric evaluation, the resident returned to the facility without increased monitoring. In the second incident, the same resident was observed touching another female resident's breast while reaching for a coloring book. The staff separated the residents and initiated behavioral monitoring, but there was no documentation of continued monitoring after a certain period. The facility's care plan for the resident did not reflect the incidents, and there was a lack of incident reporting and proper documentation. Interviews with staff revealed inconsistencies in awareness and reporting of the incidents. Some staff were unaware of the resident's behaviors and the need for close monitoring. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the lack of immediate separation of residents and inadequate monitoring of the aggressor. The facility's failure to protect residents from abuse and ensure proper documentation and reporting led to the identification of an Immediate Jeopardy situation.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator reeducated all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur.
- Staff were reeducated to stay with the aggressor one-on-one until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the cases of two residents who were subjected to inappropriate sexual behavior by another resident. The incidents involved a resident with a history of inappropriate sexual behaviors, who was not adequately monitored or managed according to the facility's policies. In one incident, a resident with dementia and other cognitive impairments was observed grabbing the breast of another resident in the dining room. Despite the resident's known history of inappropriate sexual behavior, the facility did not implement sufficient monitoring or interventions to prevent further incidents. The staff failed to maintain one-on-one monitoring or update care plans to reflect the resident's behaviors, which were necessary steps outlined in the facility's abuse and neglect policy. Another incident involved the same resident inappropriately touching a different resident's breast. The staff's response was inadequate, as they did not initiate one-on-one monitoring or update the care plans to address the behavior. The facility's failure to follow its own policies and procedures for preventing and addressing abuse and neglect placed residents at risk of further harm.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator in-service all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse.
- Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
Deficiency in Nursing Leadership and RN Coverage
Penalty
Summary
The facility failed to ensure compliance with federal guidelines requiring a full-time Director of Nursing (DON) and registered nurse (RN) coverage for 8 consecutive hours, 7 days a week. The deficiency was identified through interviews and record reviews, revealing that the facility did not have a full-time DON from August 16, 2024, to September 30, 2024. Additionally, there was a lack of RN coverage on multiple days throughout September 2024, specifically on September 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, and 30. These lapses in staffing could potentially place residents at risk due to insufficient nursing oversight and care. Interviews with the facility's Administrator and RNC T highlighted a lack of awareness and communication regarding staffing requirements and the use of agency staff to fill RN positions. The Administrator admitted to not knowing that agency nurses could be used for RN coverage until late September 2024. Furthermore, the facility did not have a policy in place for ensuring DON or RN coverage, relying instead on federal guidelines. The absence of a DON and RN coverage was attributed to the medical records staff handling scheduling, whose last day was September 20, 2024, and the facility's ongoing recruitment efforts for a new DON.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was observed in three residents who were receiving PRN anti-anxiety and antipsychotic medications without a documented stop date or justification for continuation beyond 14 days. The lack of proper documentation and monitoring could lead to residents receiving unnecessary medications and not achieving the intended therapeutic benefits. Resident #1, who had a history of dementia, delusional disorder, and major depressive disorder, was prescribed Ativan both orally and via injection for anxiety and agitation. Despite receiving the medication multiple times, there was no documentation of a stop date or monitoring of behaviors as required. The pharmacy had recommended discontinuation or justification for continuation, but the facility deferred the decision to the psychiatry team without proper follow-up. Additionally, there were no consent forms for Ativan in the resident's records. Similarly, Resident #2, diagnosed with schizoaffective disorder and dementia, received PRN Ativan injections without a pharmacy review or documented stop date. Resident #3, with diagnoses including dementia and anxiety, also received Lorazepam without a stop date or documented rationale for continuation. Interviews with facility staff revealed a lack of awareness and understanding of the requirement for a 14-day stop date for PRN psychotropic medications, as well as inadequate monitoring of residents' behaviors and side effects.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents to the State Survey Agency within the required two-hour timeframe. The incidents involved a resident with a history of inappropriate sexual behaviors, who was reported to have touched the breasts of two female residents on separate occasions. Despite the facility's policy requiring immediate reporting of such allegations, the incidents were not reported to the state agency, potentially placing residents at risk of abuse, physical harm, mental anguish, and emotional distress. The first incident occurred when a resident with dementia and other cognitive impairments was reported to have inappropriately touched another resident's breast in the dining room. The staff attempted to redirect the resident and contacted the medical director, who prescribed medication for agitation. The resident was monitored and eventually sent to a behavioral hospital for evaluation. However, there was no incident report completed, and the state agency was not notified of the sexual abuse allegation. In the second incident, the same resident was reported to have touched another female resident's breast. The staff separated the residents and initiated behavioral monitoring, but again, the incident was not reported to the state agency. Interviews with staff revealed a lack of clarity and communication regarding the reporting process, with some staff members unaware of the requirement to report such incidents within two hours. The facility's failure to report these allegations as required by federal guidelines highlights a significant deficiency in their abuse prevention and reporting procedures.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for five residents, leading to significant weight loss and lack of appropriate dietary interventions. The report highlights that the facility did not offer therapeutic diets when ordered by healthcare providers, nor did it have systems in place to monitor weight changes effectively. This deficiency was observed in all five residents reviewed for weight loss and nutrition. Resident #1 experienced a significant weight loss of 47 lbs. over one month, 51 lbs. over three months, and 49 lbs. over six months. Despite having a care plan that included monitoring appetite and weight, there were no specific care plans addressing weight loss. The resident frequently refused meals, and there was no documentation of dietary supplements being offered. Interviews with staff revealed a lack of awareness regarding the resident's nutritional needs and the absence of communication with the physician about the resident's weight loss. Similar issues were noted with Residents #2, #3, #4, and #5, who all experienced significant weight loss without appropriate dietary interventions or physician notifications. The Registered Dietician's recommendations for supplements and dietary changes were not implemented, and there was a lack of communication between the dietician, nursing staff, and physicians. The facility's policy on weight assessment and intervention was not followed, contributing to the residents' continued weight loss and potential health decline.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper management of a central line dressing for a resident. The resident, a male with a history of cellulitis, hypertension, diabetes, and Charcot's joint syndrome, had a physician's order for the dressing of his PICC line to be changed every seven days. However, observations revealed that the dressing had not been changed since the resident's admission, which was confirmed by the resident himself. Interviews with the medical director, administrator, and nursing staff indicated a lack of adherence to the dressing change schedule, which is crucial for preventing infections. Additionally, the facility's treatment nurse demonstrated inadequate hand hygiene practices during wound care for the same resident. The nurse failed to change gloves and perform hand hygiene between glove changes, after picking up an item from the floor, and before and after entering the resident's room. These actions were observed during wound care procedures, where the nurse used the same piece of gauze for multiple incisions and did not follow proper hand hygiene protocols. The medical director and director of nursing acknowledged these lapses and emphasized the importance of hand hygiene in preventing the spread of infections. The facility's policies on infection control, central venous catheter dressing changes, and hand hygiene were not followed, contributing to the deficiencies observed. The policies outlined the necessity of regular dressing changes and proper hand hygiene to prevent infections, yet staff interviews and observations indicated a lack of compliance. The treatment nurse's actions, such as not changing gloves between treating different wound areas and leaving the room without performing hand hygiene, further highlighted the facility's failure to adhere to its own infection control protocols.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a male with multiple diagnoses including cellulitis, hypertension, diabetes, and Charcot's joint syndrome, was admitted to the facility but did not have a baseline care plan in place. This omission was identified during a record review, which showed no baseline care plan available for the resident. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed that a baseline care plan should have been completed upon admission to guide the care provided to the resident. The MDS Coordinator acknowledged that the baseline care plan was supposed to be triggered upon admission, but it either did not trigger or was deleted. The DON and Administrator both emphasized the importance of baseline care plans as a framework for staff to understand and provide the necessary care to maintain the resident's quality of life. The facility's policy, revised in December 2016, mandates that a baseline care plan be developed within 48 hours of admission to ensure the resident's immediate care needs are met. The failure to adhere to this policy could place newly admitted residents at risk of receiving inadequate care and services.
Failure to Maintain and Revise Resident Care Plan
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident. Specifically, the care plan for a resident was closed erroneously on a date in December, despite the resident not being discharged. This oversight resulted in the care plan not being updated or revised quarterly as required. The resident, who was readmitted to the facility with multiple diagnoses including dementia, blindness, heart disease, schizoaffective disorder, hypertension, bipolar disorder, and Parkinson's disease, was severely cognitively impaired and required substantial assistance with activities of daily living. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the care plan should have been active and revised quarterly, as well as after any significant change in the resident's condition. The MDS Coordinator acknowledged the error and noted that the care plan should have been revised in March and June, but these revisions were not completed due to the care plan being closed. The facility's policy mandates that comprehensive, person-centered care plans be developed within seven days of the completion of the required comprehensive assessment and revised as the resident's condition changes, at least quarterly, and upon readmission from a hospital stay.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM) and mobility issues, specifically neglecting to assess and provide necessary equipment such as hand rolls or positioning devices. This deficiency was identified for a resident who had multiple diagnoses, including epilepsy, mood disorder, intellectual disabilities, and functional quadriplegia, among others. Despite these conditions, the resident's annual assessment noted no impairment in ROM, and there was no care plan or interventions related to her contractures. The resident's occupational therapy (OT) assessment indicated severe flexed contractures in the right upper extremity, poor sitting balance, and decreased ROM, yet she was discharged from OT services due to lack of a payer source without recommendations for a hand roll or positioning device. Observations revealed that the resident's right hand was contracted, with long nails and debris between the fingers, and no roll or brace was provided. Interviews with facility staff, including the Director of Nursing (DON) and the Rehabilitation Director, revealed a lack of awareness and documentation regarding the resident's need for contracture management. The facility's policies on joint mobility and rehabilitative nursing care outlined the need for assessments upon admission and regularly thereafter, as well as the implementation of a restorative program to prevent deterioration of joint mobility. However, these protocols were not followed for the resident in question, leading to a failure in providing necessary care and services to maintain her highest level of well-being. The deficiency was further compounded by the absence of documentation and communication among staff regarding the resident's needs and the lack of a structured plan for contracture management.
Improper Discharge and Readmission Denial
Penalty
Summary
The facility failed to comply with discharge requirements for a resident diagnosed with schizophrenia, persistent mood disorder, and requiring a gastrostomy tube. The resident was initially transferred to a behavioral hospital after an incident where she placed a pillow over her roommate's face. Despite a 30-day discharge notice being issued, the facility did not allow the resident to return after treatment at the behavioral hospital, citing safety concerns and lack of available space in the secure unit. The facility's administrator and staff, including the DON and ADON, were involved in the decision not to readmit the resident before the 30-day notice period ended. The resident was sent back to the facility from Behavioral Hospital B, but the administrator instructed staff not to accept her, leading to her being taken to another hospital. Interviews with staff and the resident's responsible party revealed that the facility had already given the resident's bed to another individual and blocked communication with the resident's family. The resident was left at a local hospital, where she displayed no aggressive behaviors and was described as having childlike behaviors. The facility's actions were contrary to their policy, which requires a 30-day written notice for discharge. The ombudsman confirmed that the facility discharged the resident before the notice period ended, and efforts were being made to find alternative placement for the resident.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its written policy regarding the readmission of residents following hospitalization or therapeutic leave, specifically in the case of a resident who was hospitalized for behavioral issues. The resident, who had a history of schizophrenia, persistent mood disorder, and required a gastrostomy tube, was initially admitted to the facility in July 2022. After an incident where the resident placed a pillow over a roommate's face, she was transferred to a behavioral hospital. Despite a 30-day discharge notice being issued, the facility did not allow the resident to return before the notice period ended, citing safety concerns and lack of available space in the secure unit. The facility's administrator and staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), were involved in the decision not to readmit the resident. The administrator stated that the behavioral hospital had discharged the resident prematurely, and the facility had already assigned her bed to another resident. The DON and ADON confirmed that they were instructed by the administrator not to accept the resident back, even though the effective date of the discharge notice had not yet passed. The resident was subsequently taken to another hospital after vomiting in the van outside the facility. Interviews with various parties, including the resident's responsible party, the case manager at the hospital, and the ombudsman, revealed that the facility had blocked communication with the resident's family and had not returned calls. The resident was on a waiting list for a state mental hospital, and the facility was working to secure her placement there. However, the premature discharge and refusal to readmit the resident before the 30-day notice period ended resulted in her being left at a local hospital, where she was observed to be in good spirits and without aggressive behaviors.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve resident grievances, specifically for one resident who expressed a grievance about a Certified Nursing Assistant (CNA). The resident, who was cognitively intact despite having dementia and schizophrenia, reported to a Certified Medication Aide (CMA) that she did not want a particular CNA to enter her room or provide care, citing feelings of unsafety and fear. However, the grievance was not documented or reported to the Grievance Official or the Administrator, as required by the facility's policy. The resident's care plan noted a history of confabulation, but she was able to make herself understood and understood others, indicating her grievance should have been taken seriously. Interviews with staff revealed that the grievance was known but not acted upon. The CMA acknowledged the resident's complaint but did not fill out a grievance form or notify the appropriate personnel. The CNA involved was aware of the resident's discomfort but did not report the grievance either. The Administrator and the Director of Nursing (DON) were unaware of the grievance, and the facility's grievance records showed no documentation of the resident's complaint. The facility's policy requires that grievances be documented and forwarded to the Grievance Official, but this process was not followed, leading to the deficiency.
Failure to Implement Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with aggressive behaviors. The resident, who was diagnosed with encephalopathy, dementia, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit, exhibited physical aggression towards staff members. Despite these behaviors being documented in the resident's quarterly MDS assessment, there was no care plan addressing the aggression. On a specific date, the resident exhibited aggressive behaviors, including scratching, punching, and kicking a CNA who was attempting to provide care. The CNA, who had been employed at the facility for two weeks, reported the incident to an LVN. Two other CNAs attempted to assist with the resident's care but were also met with aggression, leading them to leave the room to allow the resident to calm down. The facility's policy requires that care plans include measurable objectives and timetables to meet residents' needs, but this was not followed in this case. Interviews with facility staff, including CNAs, an LVN, and the Administrator, revealed that the omission of a care plan for the resident's aggressive behavior was a mistake. The MDS Coordinator, responsible for completing care plans, acknowledged the oversight. The Administrator emphasized the importance of including unusual or special care needs in the care plan to ensure appropriate care for residents.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for three residents reviewed for skin assessments. Specifically, the facility did not conduct weekly skin assessments for these residents, which were necessary to monitor and address potential skin integrity issues. This lapse in care was identified through interviews and record reviews, revealing that the residents were at risk of not receiving adequate care and medical interventions to maintain their health and prevent worsening conditions. Resident #1, who had multiple diagnoses including dementia, heart disease, and chronic fragile skin, was supposed to receive weekly skin assessments as per physician orders. However, there was no record of these assessments being conducted from April 10, 2024, through May 13, 2024. Similarly, Resident #2, who was at risk for skin breakdown due to conditions like cellulitis and edema, did not have weekly skin assessments documented from April 10, 2024, through May 14, 2024. Resident #3, with conditions such as hemiplegia and diabetes, also lacked documented weekly skin assessments from April 18, 2024, through May 22, 2024. Interviews with facility staff, including the Administrator and various nurses, revealed that the failure to conduct these assessments was due to a lack of scheduling and notification in the electronic record system. The previous Director of Nursing (DON) had not updated the system to reflect the new schedule for skin assessments, leading to missed assessments. Staff members indicated that they relied on electronic triggers to complete assessments and were unaware of the need to perform them without these notifications. The Administrator acknowledged the oversight and the risk it posed to residents' care.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene, specifically in relation to nail care. The resident, who had severe cognitive impairment and required assistance with personal hygiene, was observed with long and jagged fingernails, approximately 1/4 inch past the fingertips. The resident's care plan included interventions to ensure nails were clipped due to the risk of impaired skin integrity and self-inflicted skin tears. However, there was no documentation of nail trimming for the resident in the previous 30 days. Interviews with staff revealed a lack of awareness and documentation regarding the resident's nail care. A CNA stated that she did not notice the resident's nails being too long and could not recall when they were last trimmed. The Director of Nursing (DON) was unable to locate care sheets for nail trimming and stated that aides were expected to complete nail care for non-diabetic residents. The Administrator expressed that staff were expected to keep residents' nails trimmed to prevent potential negative outcomes such as scratches or skin tears.
Failure to Notify Physician and Responsible Party of Significant Change
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for two residents. Specifically, the facility did not notify Resident #1's physician and responsible party after Resident #1 placed a pillow over Resident #2's face and said she tried to kill her. Similarly, the facility did not notify Resident #2's physician after she reported the incident involving Resident #1. Resident #1, who had diagnoses including schizophrenia, persistent mood disorder, and anxiety disorder, was admitted to the facility on a specific date. Her care plan indicated she was at risk for manic episodes and increased behaviors, and interventions included monitoring for delusions, hallucinations, and aggressive behaviors. Despite these precautions, there were no care plans related to homicidal ideations. On the day of the incident, Resident #1 admitted to trying to harm Resident #2, but the facility staff failed to notify the physician or the responsible party immediately. Resident #2, who had diagnoses including dementia with agitation, major depressive disorder, and schizophrenia, was also admitted to the facility on a specific date. Her care plan indicated she was at risk for further decline and injury due to her cognitive impairments. After the incident, Resident #2 reported feeling unsafe, but the facility staff did not notify her physician immediately. The delay in notification and lack of immediate action by the facility staff could have placed both residents at risk of further harm or decline in their health status.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents the right to be free from abuse for two residents. One incident involved a resident who self-propelled her wheelchair into another resident's room and was pulled out of her wheelchair onto the floor. The resident who pulled her out expressed frustration and used abusive language, indicating a lack of understanding of the facility's policy against physical aggression. The incident was reported, but there was no documentation of immediate corrective actions or notifications to relevant parties at the time of the incident. Another incident involved a resident placing a pillow over her roommate's face with the intent to harm. The resident admitted to trying to kill her roommate and requested to be sent to a mental institution. The incident was reported to the administrator, but there was a delay in hiring additional staff for the secure unit and in notifying the physician and responsible parties. The resident who attempted the harm was not immediately transferred to a behavioral hospital, and there was a lack of documentation in the clinical record about the incident. The facility's policies on abuse and neglect were not adequately followed, as evidenced by the lack of immediate and appropriate responses to the incidents. Staff interviews revealed inconsistencies in reporting and handling such incidents, and there was a failure to ensure the safety and well-being of the residents involved. The facility's actions and inactions led to a situation where residents were at risk of further harm and abuse.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of schizophrenia, mood disorder, and anxiety disorder. This resident, who had moderate cognitive impairment, was involved in two separate incidents of aggression towards other residents. In the first incident, the resident pulled another resident out of her wheelchair after the latter entered her room. Despite this aggressive behavior, the facility did not place the resident under one-on-one supervision or move her to a private room. In the second incident, the same resident attempted to suffocate her roommate by placing a pillow over her face. Again, the facility failed to implement immediate one-on-one supervision or other safety measures to prevent further harm. The facility's response to these incidents was inadequate. The staff did not document the incidents properly, nor did they notify the physician, police, or responsible parties in a timely manner. The Director of Nursing (DON) acknowledged that the resident should have been transferred to a behavioral hospital for evaluation but failed to take immediate action. Additionally, the facility did not have a care plan in place for the resident's homicidal ideations, and there were no additional safety measures implemented to protect other residents in the secure unit. Interviews with staff revealed a lack of proper training and understanding of the facility's policies on managing aggressive behaviors. The Administrator admitted that no additional safety measures had been put in place following the incidents. Observations showed that the resident was left alone in her room without one-on-one supervision, even after the severity of her actions was known. This lack of immediate and appropriate response placed other residents at risk of physical harm and emotional distress.
Failure to Update Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #1's care plan was not updated to reflect incidents of physical aggression towards other residents, including pulling Resident #3 out of her wheelchair and attempting to smother her roommate, Resident #2, with a pillow. The MDS nurse was unaware of these incidents and therefore did not update the care plan, which could result in staff being unaware of the changes in Resident #1's behavior and needs. Resident #2's care plan was also not updated to reflect the altercation where Resident #1 attempted to smother her with a pillow. Despite the incident being documented in clinical notes and an incident report, the MDS nurse did not update the care plan because she was not informed of the event. This oversight could lead to Resident #2 not receiving the necessary care and protection following the altercation. Similarly, Resident #3's care plan was not updated after she was pulled out of her wheelchair by Resident #1. The MDS nurse was not aware of this incident and therefore did not make the necessary updates to the care plan. This failure to update care plans with significant changes in resident behavior and incidents could place residents at risk of not receiving appropriate care and interventions.
Failure to Utilize AED During CPR on Unresponsive Resident
Penalty
Summary
The facility failed to ensure basic life support, including CPR and the use of an automated external defibrillator (AED), was provided to a resident (Resident #1) who required emergency care prior to the arrival of emergency medical personnel. Resident #1, a [AGE] year old male with multiple complex medical conditions including diabetes, heart failure, and respiratory failure, was found unresponsive, not breathing, and without a pulse on [DATE]. Despite being a full code with physician orders for CPR, staff did not utilize the AED when attempting resuscitation efforts. The resident was pronounced deceased after paramedics took over the resuscitation attempts. During interviews, it was revealed that the licensed vocational nurse (LVN A) who initiated CPR on Resident #1 did not call for the AED or use it during the resuscitation efforts. LVN A mentioned being busy with CPR and not thinking about the AED during the emergency. The Director of Nursing (DON) acknowledged that the AED was not utilized during the incident and stated that staff should have called for the AED and the crash cart. The facility's crash cart checklists did not include an AED inspection, and during observations, it was noted that the AED was located down the hall from the crash cart, with no specific check-off list for its inspection.
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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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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