Harmony Care At Brookshire
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookshire, Texas.
- Location
- 710 Hwy 359 S, Brookshire, Texas 77423
- CMS Provider Number
- 675700
- Inspections on file
- 32
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harmony Care At Brookshire during CMS and state inspections, most recent first.
Two residents with cognitive impairment and dysphagia were assisted with meals by an LVN and a CNA who stood over them while feeding, contrary to facility policy requiring staff to sit at eye level to preserve dignity and assess swallowing. One resident, fully dependent for eating and on a mechanical soft diet, was fed by an LVN standing at her side. Another resident on a pureed diet, care planned as independent with eating but needing setup help, was intermittently fed by a CNA who stood beside him, even though the resident demonstrated ability to self-feed part of his meal. Multiple staff, including the ADON and DON, acknowledged that staff are expected to sit when feeding residents, and a resident reported feeling bad when staff stood while feeding him.
The facility operated without a licensed administrator for an extended period, with administrative duties informally reassigned to the DON and department heads, none of whom were licensed administrators. Staff and residents were unaware of a designated acting administrator, and required documentation was not provided, resulting in a failure to meet regulatory requirements for facility administration.
The facility did not provide required training to staff on abuse, neglect, and exploitation reporting procedures, nor did it update or communicate the identity of the current Abuse Coordinator after the previous coordinator was terminated. Six direct care staff members could not identify the Abuse Coordinator or describe the reporting process, and the facility could not produce documentation of recent training.
A resident with severe cognitive and physical impairments was not relocated during active sheetrock repairs in her room, resulting in her exposure to construction debris and dust. Only her roommate was moved, and staff cited limited space and challenges with memory care residents as reasons for not relocating both individuals. The room remained unclean during the repairs, contrary to facility policy requiring a clean and homelike environment.
The facility did not maintain an effective pest control program, as evidenced by the presence of live gnats in two hallways and the conference room. Observations confirmed multiple instances of gnats in these areas, and the pest control log for the past 90 days was not provided. Staff interviews revealed uncertainty about the pest control schedule and lack of communication regarding the pest issue. Documentation of pest control services was unclear about dates and locations treated.
A resident with multiple health conditions was administered 100 mg of Midodrine instead of the prescribed 10 mg due to a transcription error in the medication order. The error was not caught by the staff, leading to a significant increase in the resident's blood pressure and hospitalization for a drug overdose. The facility's failure to verify medication orders against the MAR and blister pack contributed to the incident.
A resident with severe cognitive impairment and osteoarthritis experienced unmanaged pain during incontinent care. Despite showing signs of pain, the CNA did not stop care or notify the LVN promptly. The resident's care plan required total assistance, and although there were physician orders for pain management, no pain assessments or medication administration were documented. The facility's pain assessment policy was not adhered to, resulting in unmanaged pain for the resident.
The facility failed to maintain a safe and homelike environment, with observations of disrepair such as discolored ceiling tiles, missing tiles, exposed sheetrock, and damaged handrails across multiple halls. Staff interviews revealed a lack of awareness and communication regarding these issues, with the Facility Maintenance Director and other staff unaware of the extent of the problems. Residents reported that some issues had been ongoing for a significant time, and the lack of maintenance logs contributed to the facility's failure.
The facility's kitchen failed to meet food safety standards, with uncovered and undated food items, unsanitary conditions, and lack of regular cleaning. Observations revealed discolored ceiling vents, stained ice machines, and a deep fryer with food particles. The Dietary Manager confirmed the absence of a deep cleaning since May 2024, and no cleaning schedule was provided.
The facility failed to submit complete and accurate direct care staffing information to CMS for the 4th quarter of FY 2024, lacking 24-hour licensed nursing/staff coverage. The Administrator and BOM were unsure of the submission process, and the corporate office failed to submit the PBJ for two quarters, leading to the termination of the responsible company. The facility also lacked a policy for PBJ submissions.
The facility failed to manage medications properly, with expired and discharged residents' medications found in multiple medication carts. Staff interviews confirmed that these medications should have been removed to prevent errors and potential theft.
The facility failed to properly label and store medications in two medication carts, with issues such as opened and undated medications, handwritten labels, and insulin pens not in original packaging. Additionally, a medication cart was left unlocked and unattended, compromising security. Interviews with staff confirmed these practices were against facility policy.
The facility failed to maintain privacy and confidentiality for two residents. An LVN left a computer screen unlocked, displaying a resident's medication information, while administering care. Additionally, a CNA did not provide privacy during incontinent care for another resident, leaving the door open and privacy curtain unpulled. Both incidents were acknowledged by staff and recognized as violations of resident rights.
A resident's MDS and care plan inaccurately indicated she was on anticoagulant and antiplatelet therapy, despite no physician orders for such medications. The resident, with severe cognitive impairment, was not receiving these medications at the time of assessment. Interviews with staff revealed the medication had been discontinued prior to the MDS assessment, highlighting a documentation error.
The facility failed to develop comprehensive care plans for two residents, one receiving hospice care and another residing in a memory care unit. The care plans lacked necessary components, such as hospice services and memory care unit residence, potentially affecting the residents' care. Interviews with staff revealed gaps in the interdisciplinary team's care plan development process.
Two residents in an LTC facility did not receive necessary personal grooming services, specifically shaving, due to staff's inconsistent understanding and execution of the facility's policy. One resident with severe cognitive impairment and another with moderate impairment and blindness were observed with facial hair, despite expressing a desire to be shaved. The lack of proper documentation and communication among staff contributed to this deficiency.
A resident with severe cognitive impairment and frequent incontinence did not receive proper incontinent care from a CNA, who failed to clean the resident's groin, buttocks, or open labia. The CNA placed a new brief without changing gloves, leaving residual stool, which could increase infection risk. The CNA cited the resident's pain as a factor, and the facility's policy lacked specific guidance on cleaning the labia and groin area.
A resident with a gastrostomy tube was at risk due to RN C's attempt to administer crushed potassium chloride ER, despite knowing it should not be crushed. The resident, with a history of heart failure and hypokalemia, was prescribed the medication to be given via PEG-Tube. The DON confirmed that crushing the medication could lead to inadequate dosage. The facility's policy prohibits crushing extended-release tablets, yet RN C did not adhere to this guideline.
A CNA failed to follow proper hand hygiene protocols during incontinent care for a resident with severe cognitive impairment and multiple medical conditions. The CNA did not wash hands before donning gloves, used the same gloves throughout the procedure, and did not adequately clean the resident, contrary to the facility's infection control policy.
A facility failed to regularly inspect and maintain bed frames and mattresses, resulting in a resident experiencing a fall due to significant gaps between the mattress and bed frame. The resident, with multiple health conditions and requiring assistance for bed mobility, reported a fall that led to a skin tear and a swollen finger. Observations confirmed the mattress did not fit well, posing a risk of injury.
The facility failed to maintain a safe and sanitary environment, with issues such as dirty floors, unsanitary bathrooms, and broken fixtures observed on multiple halls. Staff interviews revealed that short staffing contributed to delays in addressing these problems, and the new housekeeping supervisor was working to organize cleaning efforts. The facility's policy emphasizes a homelike environment, but these standards were not met, particularly in the secured unit.
A resident with mobility issues was transported to dialysis in a personal vehicle due to a facility van issue, requiring her to use a walker instead of her wheelchair. After dialysis, she was left to wheel herself back to her room without assistance, contrary to her care plan. Facility staff were unaware of the transportation arrangements, and the driver did not ensure the resident's safety at the dialysis center.
Two residents in an LTC facility did not receive scheduled showers due to staffing shortages and inadequate documentation. A resident with Parkinson's and dementia had not been showered since early May, while another with severe cognitive impairment missed a scheduled shower. Staff interviews revealed issues with communication and documentation, contributing to the deficiency.
A resident requiring feeding assistance was consistently served cold meals due to staff delays, despite her preference for hot food. Interviews revealed that there was often only one aide available to feed multiple residents, leading to food cooling before it could be served. The ADON acknowledged the issue, agreeing that meals should be warmed if necessary, aligning with the facility's policy on treating residents with dignity.
Failure to Maintain Dignity and Proper Positioning During Assisted Feeding
Penalty
Summary
The deficiency involves staff failing to treat residents with respect and dignity and to provide meal assistance in a manner that promotes quality of life, as required by facility policy and resident rights. Surveyors observed that a licensed vocational nurse (LVN B) stood while feeding lunch to Resident #1 in the dining room, rather than sitting at eye level. Resident #1, an elderly female with dementia, dysphagia following cerebrovascular disease, epilepsy, Parkinson’s disease, and depression, had a severely impaired BIMS score of 5 and was dependent on staff for eating. Her care plan identified risk for malnutrition related to a mechanically altered diet and need for assistance with eating, with interventions to monitor for signs and symptoms of dysphagia. Despite this, LVN B stood at the resident’s left side while feeding a mechanical soft diet. Surveyors also observed that CNA A stood while assisting Resident #2 with his lunch. Resident #2, an elderly male with cerebral infarction, GERD without esophagitis, epigastric pain, lack of coordination, and dysphagia, had a BIMS score of 8 indicating moderately impaired cognition. His MDS showed he required setup or clean-up assistance with eating, and his care plan noted an ADL self-care performance deficit related to fatigue and impaired balance, with an intervention stating he was independent with eating. His physician orders included a regular diet with pureed texture and thin liquids. During the meal observation, CNA A initially set up the food and then began feeding Resident #2 while standing at his right side, left the resident briefly during which the resident fed himself ice cream, and then resumed feeding while still standing until instructed by another CNA (CNA C) to sit. Interviews confirmed that the observed feeding practices were inconsistent with facility expectations and policies. CNA C stated she was taught in CNA school to never stand while feeding a resident but to sit at eye level to avoid making the resident feel threatened and to respect the resident. LVN B acknowledged that staff should not stand while feeding residents and admitted he knew he should sit, later recognizing that being fed by someone standing would feel disrespectful. CNA A reported he had been instructed to sit and make eye contact when feeding residents but chose to stand because he saw LVN B standing and did not want LVN B to “look bad.” The ADON and DON both stated staff were supposed to sit at eye level when assisting with feeding to assess swallowing and preserve dignity and respect. Resident #2 reported he did not like when staff stood while feeding him, stating it made him feel bad. Facility policies on Assistance with Meals and Resident Rights specified that residents should be assisted with meals in a manner that meets individual needs, with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals, and that employees must treat all residents with kindness, respect, and dignity.
Failure to Maintain Licensed Administrator and Effective Facility Administration
Penalty
Summary
The facility failed to ensure effective administration to maintain the highest practicable well-being of each resident by operating without a licensed administrator from 08/20/2025 to 09/13/2025. The former administrator was terminated on 08/19/2025, and there was no record of a licensed interim or permanent replacement during the subsequent period. Interviews with the nurse supervisor, DON, and VP of Operations confirmed that no state-licensed nursing home administrator was present on staff, and administrative duties were informally reassigned among department heads, none of whom were licensed administrators. The VP of Operations, who holds a state administrator license, was not physically present at the facility and communicated with department heads remotely. Staff interviews indicated a lack of awareness of a designated acting administrator, and administrative responsibilities were primarily handled by the DON. Residents interviewed during the survey reported not knowing who the administrator was since the previous administrator's departure, though they expressed no immediate safety concerns and stated they would report issues to the DON. The facility was unable to provide documentation of a designated acting administrator or a signed administrator job description when requested. The facility's policy requires a licensed administrator to be responsible for day-to-day operations, including ensuring adequate staffing and compliance with laws and regulations, but this requirement was not met during the period in question.
Failure to Train Staff on Abuse Reporting Procedures and Update Abuse Coordinator Information
Penalty
Summary
The facility failed to ensure that all staff were trained in the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property. Six out of six employees reviewed had not received training on the identity of the Abuse Coordinator or the procedures for reporting abuse. Observations during the onsite visit revealed that the facility had not updated the signage and posting of the facility's Abuse Coordinator, which still reflected the contact information of a former employee who was terminated nearly a month prior. Interviews with the Director of Nursing and the VP of Operations confirmed that the facility had not provided updated training or information to staff regarding the new Abuse Coordinator or the reporting process. During staff interviews, all six direct care staff members were unable to identify the current Abuse Coordinator and reported not having received recent or updated in-service training on abuse reporting protocols. The facility was unable to provide documentation or sign-in sheets showing that such training had been conducted within the last 30 days, despite multiple requests. This lack of training and updated information on abuse reporting procedures was directly observed and confirmed through interviews and record review.
Failure to Maintain Safe and Homelike Environment During Room Repairs
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for a resident with severe cognitive impairment and significant physical limitations. Maintenance staff conducted sheetrock repairs, including sanding drywall, in the resident's room while she remained present in close proximity to the work area. Observations revealed large pieces of debris and dust on the floor and windowsill near the resident, and the room was not cleaned during or after the repairs. The resident, who required supervision or assistance for transfers and did not use mobility devices, was exposed to the ongoing construction environment. Interviews with facility staff indicated that only the roommate closest to the repairs was relocated, while the resident remained in the room due to limited space and challenges associated with memory care residents wandering. The ADON and Maintenance Director both acknowledged that efforts were made to keep residents out of their rooms during repairs, but these were not always successful. The facility's policy required a clean, sanitary, and orderly environment, but this was not maintained during the repair work in the resident's room.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live gnats in two of five hallways (Hall 100 and Hall 400) and the conference room. Observations on multiple occasions revealed approximately 10 gnats in the conference room, 12 gnats near the dining area in Hall 100, and 5 gnats in Hall 400. The pest control log for the last 90 days was requested but not provided. The pest control service documentation was unclear regarding the date of service and the specific locations treated. Interviews with facility staff revealed a lack of awareness and communication regarding the gnat issue. The ADON acknowledged a recent problem with gnats and stated that staff had been educated to pick up food trays promptly, but was unsure of the pest control schedule. The Maintenance Director reported that pest control visits occurred monthly or as needed but was not aware of any gnat issues due to lack of notification. The Administrator confirmed the last pest control visit but was not aware of any current complaints or additional follow-up. The facility's pest control policy states an ongoing program is maintained to keep the building free of insects and rodents.
Medication Administration Error Leads to Resident Overdose
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications, leading to a significant medication error involving a resident. The resident, who had a history of dementia, diabetes, hypotension, psychosis, lack of coordination, and hypertensive heart disease with heart failure, was prescribed Midodrine to manage hypotension. However, on a specific date, the resident was administered 100 mg of Midodrine instead of the prescribed 10 mg, resulting in a severe increase in blood pressure and necessitating hospitalization for a drug overdose. The error occurred due to a transcription mistake where the order was incorrectly entered as 10 tablets instead of 10 mg. This mistake was not caught by the staff responsible for administering the medication, leading to the resident receiving an overdose. Interviews with various staff members, including the Medical Director, nurses, and medication aides, revealed that the error was identified after the medication was administered, and the resident's blood pressure had significantly increased. The staff failed to verify the medication order against the medication administration record (MAR) and the blister pack, which contributed to the error. The facility's pharmacy consultant and nursing staff did not adequately review and verify the medication orders, which allowed the error to go unnoticed until after the medication was administered. The facility's policies and procedures for medication administration and verification were not effectively followed, leading to the resident's adverse reaction and subsequent hospitalization. The incident highlights a breakdown in communication and verification processes within the facility's pharmaceutical services.
Failure to Provide Adequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #29, who required such services. During an observation, CNA A was seen performing incontinent care on Resident #29, who was grimacing, moaning, and verbally expressing pain. Despite these clear signs of discomfort, CNA A did not stop the care process to address the resident's pain. Furthermore, CNA A did not notify LVN B about the resident's pain in a timely manner after the morning care, which could have led to further assessment and intervention. Resident #29, a female with severe cognitive impairment and a history of osteoarthritis, was admitted to the facility with a need for assistance with personal care and pain management. The resident's care plan indicated a requirement for total assistance with activities of daily living, including incontinent care. Despite having physician orders for pain management medications, there was no documentation of pain assessment or administration of pain relief in the resident's records for November and December 2024. Additionally, a nurse's note indicated the resident had a deep venous thrombosis, which could contribute to her pain, yet the facility's pain assessment policy was not followed, leading to unmanaged pain for the resident.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by numerous observations of disrepair and uncleanliness across multiple halls. Observations revealed discoloration on ceiling tiles, missing floor and wall tiles, exposed sheetrock, chipped wall paint, damaged exit door handles, and damaged handrails. These issues were noted in various rooms and common areas, including the 100-hall, 400-hall, and 500-hall, as well as the main dining room and corridors. Interviews with staff and residents highlighted a lack of awareness and communication regarding the maintenance issues. The Facility Maintenance Director (FMD), who began employment in November 2024, stated that he was not informed about the missing tiles, loose faucets, peeling paint, and other issues. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) also expressed unawareness of these problems. The Housekeeping Supervisor (HS) mentioned that her team was responsible for identifying and reporting damages, but she was not aware of any specific issues in the resident rooms or facility areas. Residents and staff reported that the disrepair had been ongoing for some time, with one resident stating that the brown watermark discoloration on ceiling tiles had been present since their arrival. The FMD attributed the discoloration to a past water leak, but he was unsure of when it occurred. The lack of maintenance logs and a clear communication process for reporting and addressing maintenance issues contributed to the facility's failure to provide a safe and homelike environment for its residents.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, leading to potential risks of foodborne illness for residents. Observations revealed that food items, such as gelatin with fruit and pureed carrots, were stored in the refrigerator uncovered and undated, contrary to the facility's policy of discarding food after 72 hours. The Dietary Manager acknowledged that these items were not properly labeled or covered, which could lead to bacterial contamination. The kitchen environment was found to be unsanitary, with discolored and debris-covered ceiling vents, discolored shelves in refrigerators, and missing tiles on walls. The ice machine had stains and rust, with a consistent water puddle observed in front of it. The deep fryer was caked with stains and contained food particles in the grease. The Dietary Manager confirmed that the kitchen had not undergone a deep cleaning since her employment began in May 2024, and there was no cleaning schedule provided. Interviews with the Dietary Manager and observations highlighted the lack of regular maintenance and cleaning in the kitchen. The Dietary Manager admitted that the kitchen had not been deep cleaned and that the ice machine and deep fryer were not maintained according to the facility's cleaning policy. The Administrator and DON were shown pictures of the unsanitary conditions, and the Administrator acknowledged the need for addressing these concerns. However, no cleaning schedule was provided, and the facility's policy on food storage and equipment sanitization was not followed.
Failure to Submit Accurate Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the 4th quarter of the fiscal year 2024. This deficiency was identified through interviews and record reviews, revealing that the facility did not have licensed nursing/staff coverage 24 hours a day as required. The Administrator was unaware of who was responsible for the submission, and the Business Office Manager (BOM) was uncertain about the actions taken by the corporate office with the staffing data she provided. The BOM also lacked documentation for the Payroll-Based Journal (PBJ), which is necessary for compliance. Further investigation revealed that the corporate office had not submitted the PBJ for approximately two quarters, and the company responsible for this task was subsequently terminated. The Administrator expressed his expectation that the corporate office should have fulfilled their responsibilities. Additionally, the facility did not have a policy in place for PBJ submissions, as confirmed by the Administrator when requested for documentation.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were accurately acquired, received, dispensed, and administered according to professional standards. This deficiency was observed in three medication carts across different halls. Specifically, the 100 and 200 hall MA medication cart C contained medications belonging to discharged residents, which should have been removed to prevent medication errors. During interviews, staff acknowledged that these medications should have been pulled from the cart and given to the DON for proper disposition. The 500 hall nurse medication cart A was found to contain expired medications, as well as medications belonging to discharged and discontinued residents. An observation revealed that Breo Ellipta had expired, and control medications such as Acetaminophen-Codeine and Tramadol were still in the cart despite being discontinued or belonging to discharged residents. Staff interviews confirmed that these medications should have been removed to prevent errors and potential theft. Similarly, the 400 hall nurse medication cart B contained expired medications, including Albuterol Sulfate and Lantus insulin pen, which were past their effective dates. Discontinued and discharged residents' medications, such as fluticasone propionate and salmeterol inhalation powder, were also found in the cart. Staff interviews highlighted the importance of removing these medications to prevent ineffective treatment and potential adverse reactions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in two of the six medication carts. Specifically, the 500-hall nurse medication cart contained opened and undated medications, such as Levetiracetam and insulin pens not stored in their original packaging. The 400-hall nurse medication cart also had similar issues, with opened and undated medications, handwritten resident names on medication containers, and insulin pens not stored in their original packets. Interviews with the Assistant Director of Nursing (ADON) and Registered Nurse (RN) confirmed that medications should be stored in their original packaging to ensure proper administration instructions and expiration dates are followed. Additionally, the facility failed to secure all drugs and biologicals in locked compartments, as evidenced by an incident involving the 400-hall nurse medication cart. A Licensed Vocational Nurse (LVN) left the medication cart unlocked and unattended while attending to a resident and clarifying a medication order. This lapse in security was acknowledged by the LVN, who admitted forgetting to lock the cart, and by the Director of Nursing (DON), who stated that leaving the cart unlocked was not part of the facility's practice. The facility's policies on medication management and pharmacy services were reviewed, revealing that the facility had established systems to meet regulatory requirements. However, the observed deficiencies indicate a failure to adhere to these policies, as medications were not properly labeled, stored, or secured, potentially compromising resident safety and medication efficacy.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information, as evidenced by two separate incidents involving two residents. In the first incident, a Licensed Vocational Nurse (LVN) left a computer screen unlocked and visible while administering care to a resident, displaying the resident's name and medication information. This oversight was acknowledged by the LVN, who admitted forgetting to lock the computer screen, and was confirmed by the facility's Administrator and Director of Nursing (DON), who recognized it as a violation of HIPAA regulations. In the second incident, a Certified Nursing Assistant (CNA) failed to provide privacy for a resident during incontinent care by not closing the entrance door or pulling the privacy curtain. The resident's roommate, who was disoriented but awake, was present in the room during the care. The CNA admitted to forgetting to provide privacy due to nervousness. The DON emphasized the importance of treating all residents with dignity and respect, as outlined in the facility's nursing policy on resident rights.
Inaccurate Medication Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the status of a resident, identified as Resident #7, regarding her medication regimen. The resident's Minimum Data Set (MDS) and care plan inaccurately indicated that she was on anticoagulant and antiplatelet therapy, despite there being no physician orders for such medications. This discrepancy was discovered during a review of the resident's records, which included her admission record, MDS assessment, and care plan. The resident, a female with severe cognitive impairment and requiring substantial assistance with activities of daily living, was not receiving anticoagulant or antiplatelet medications at the time of the assessment. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the medication had been discontinued prior to the MDS assessment. The DON acknowledged the error and noted that the care plan and MDS would need to be corrected. The inaccurate documentation could lead to staff being unaware of the resident's actual care needs, potentially impacting the quality of care provided.
Deficiency in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #22, a male with chronic obstructive pulmonary disease and receiving hospice care, did not have hospice services addressed in his care plan. Despite having a hospice care consult order, the care plan only included directives related to his Do Not Resuscitate status, lacking any mention of hospice care. Resident #65, a male with severe cognitive impairment and residing in the memory care unit, also lacked a comprehensive care plan addressing his living situation. His care plan included interventions for depression and elopement risk but did not mention his residence in the memory care unit. The absence of this information could lead to staff being unaware of the risks associated with his care and behaviors, such as wandering and elopement. Interviews with facility staff, including the Director of Nursing and the Social Worker, revealed that the interdisciplinary team was responsible for developing these care plans. However, the necessary components were not included, potentially affecting the residents' care. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timeframes, which were not adequately addressed in these cases.
Failure to Provide Necessary Personal Grooming Services
Penalty
Summary
The facility failed to provide necessary personal grooming services, specifically shaving, to two residents who were unable to perform activities of daily living (ADLs) independently. Resident #55, a female with severe cognitive impairment due to dementia and other health issues, was observed with facial hair and reported that she had not been shaved since her admission to the facility. Despite her request to be shaved, the staff did not fulfill this need, and there was a lack of clarity among the staff regarding who was responsible for shaving female residents. Interviews with various staff members, including LVNs, RNs, and CNAs, revealed inconsistencies in understanding and executing the shaving protocol, with some staff unaware of the resident's needs or the facility's policy. Resident #28, who has moderately impaired cognition and is blind in one eye, also experienced a lack of personal grooming. She was observed with facial hair and expressed feeling unkempt because she could not shave herself. The staff failed to offer shaving services consistently, and there was no documentation of her refusal to be shaved. Interviews with CNAs and LVNs indicated a lack of communication and documentation regarding the resident's preferences and needs, leading to her not receiving the necessary grooming services. The facility's failure to ensure these residents received appropriate personal grooming services could lead to discomfort and dignity issues. The staff's inconsistent understanding and execution of the facility's shaving policy contributed to this deficiency, as did the lack of proper documentation and communication regarding the residents' grooming needs and preferences.
Inadequate Incontinent Care Provided to Resident
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who was incontinent of bladder and bowel. During an observation, CNA A did not clean the resident's groin, buttocks, or open labia while providing care. The CNA used a cleaning cloth wipe after the resident had a bowel movement and placed a new brief under the resident's buttock without changing gloves, despite the presence of residual stool. This improper care practice could place residents at risk for infection. The resident involved was a female with severe cognitive impairment, requiring substantial assistance with personal hygiene and frequent incontinent care. The CNA, who had recently started working at the facility, acknowledged the failure to clean the resident properly, citing the resident's pain as a factor. The facility's policy on perineal care did not specifically address cleaning the labia and groin area, and the CNA's personnel file indicated a skill check for incontinent care had been completed shortly after hire.
Failure to Administer Medication Correctly
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the actions of RN C, who attempted to administer crushed potassium chloride extended-release (ER) to a resident with a gastrostomy tube. The resident, a male with a history of heart failure, hypokalemia, dementia, and a gastrostomy, was prescribed potassium chloride ER 20 MEQ tablet to be given via PEG-Tube once daily for low potassium. Despite knowing that potassium ER should not be crushed, RN C proceeded to crush the medication, believing it was the only way to administer it through the G tube. During an interview, the Director of Nursing (DON) confirmed that crushing potassium ER tablets would break down the extended-release mechanism, potentially leading to inadequate dosage and symptoms of hypokalemia. The facility's policy on medication administration explicitly states that extended-release tablets should not be crushed, and staff are instructed to seek assistance from a nursing supervisor or consulting pharmacist if there are any questions about medication administration. Despite these guidelines, RN C continued to crush the medication, indicating a lapse in adherence to the facility's medication administration policy.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinent care for Resident #29. CNA A did not perform proper hand hygiene before donning gloves and throughout the procedure. The CNA used the same gloves for the entire process, which included handling soiled materials and touching clean items, without changing gloves or washing hands. This practice was observed during the care of Resident #29, who had a bowel movement and required assistance due to severe cognitive impairment and physical limitations. Resident #29, a female resident with a history of multiple medical conditions including severe cognitive impairment, was dependent on staff for personal hygiene and incontinent care. During the observed incident, CNA A did not adequately clean the resident's buttock area and failed to open the labia for proper cleaning. The CNA placed soiled items on the floor and reused them without changing gloves, which is against the facility's hand hygiene policy. The resident was in pain during the procedure, which may have contributed to the CNA's oversight. Interviews with the facility's staff, including the ADON and DON, revealed that there was an expectation for staff to perform hand hygiene before and after resident contact. However, CNA A, who was newly hired, did not adhere to these protocols. The facility's policy on hand hygiene emphasizes the importance of washing hands before and after direct contact with residents and after removing gloves, which was not followed in this instance.
Failure to Inspect and Maintain Bed Equipment Leads to Safety Hazard
Penalty
Summary
The facility failed to conduct regular inspections and maintenance of bed frames, mattresses, and bed rails, leading to potential entrapment hazards for a resident. Observations revealed significant gaps between the mattress and bed frame, specifically a 4-inch gap at the head and a 2-inch gap at the foot of the bed. This deficiency was identified during a review of the resident's safety, where it was noted that the mattress did not fit well on the bed frame, posing a risk of injury from equipment malfunction, entrapment, or falls. The resident involved was a male with multiple diagnoses, including bipolar disorder, type 2 diabetes, epilepsy, and a history of falls. The resident required substantial assistance for bed mobility and had a BIMS score indicating slight cognitive impairment. The resident reported falling out of bed three days prior to the observation, which resulted in a skin tear and a painful, swollen finger. Interviews with the DON and the Administrator revealed that the mattress shifted when the head of the bed was elevated, and there was an expectation for staff to report mismatched mattresses and bed frames to maintenance.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as observed on three of the five halls. Specifically, Hall 100 exhibited numerous issues, including dirty and stained floors, unkempt and unsanitary bathrooms with strong urine odors, and broken or missing fixtures such as window blinds, baseboards, and sheet racks. Additionally, there was an accumulation of spider webs and green residue on the windows, and the toilet bowls had brown and black stains. These conditions were confirmed through observations and interviews with staff, who acknowledged the need for cleaning and maintenance. On Hall 400, similar deficiencies were noted, including missing slats in vertical window blinds, broken sheet racks, and peeling paint. Interviews with housekeeping and maintenance staff revealed that the facility was short-staffed, which contributed to the delay in addressing these issues. The housekeeping supervisor, who was new to the facility, was in the process of organizing the cleaning schedule and addressing the backlog of maintenance tasks. The facility's policy on providing a homelike environment emphasizes cleanliness, pleasant scents, and the minimization of institutional characteristics. However, the observations and interviews indicate that these standards were not being met, particularly in the secured unit and other affected areas. The administrator acknowledged the environmental issues and attributed some delays in addressing them to a recent storm, which required immediate attention to storm-related problems.
Failure to Accommodate Resident's Transportation Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically in relation to transportation to dialysis appointments. The resident, a seventy-year-old woman with end-stage renal disease and mobility issues, was taken to a dialysis appointment in a personal vehicle because the facility van was out of service. Her wheelchair could not be accommodated in the personal vehicle, and she was required to use a walker, which caused her anxiety due to her unsteadiness and fear of falling. Upon returning from dialysis, the resident, who was often tired after the procedure, was left to wheel herself back to her room without assistance. This was contrary to her care plan, which indicated she required supervision or assistance for mobility. The resident expressed concerns about the lack of assistance and the anxiety it caused her, as well as the fact that the driver did not ensure she was safely inside the dialysis center before leaving. Interviews with facility staff revealed a lack of communication and awareness regarding the transportation arrangements. The Director of Nursing was unaware of the use of a personal vehicle, and the Administrator did not see potential harm in the situation. The driver admitted to using her personal vehicle due to the van's condition and did not consistently assist the resident as required by her care plan. This lack of proper accommodation and assistance could negatively impact the resident's quality of life and safety.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for two residents, leading to deficiencies in their care. Resident #1, a sixty-eight-year-old woman with multiple health conditions including Parkinson's disease and dementia, had not received a shower since May 11, 2024, despite being scheduled for showers three times a week. Her care plan indicated a need for substantial assistance with bathing due to her cognitive and mobility impairments. The lack of documentation and failure to adhere to the shower schedule were confirmed through interviews and record reviews, highlighting a gap in the facility's care practices. Resident #2, a sixty-four-year-old man with severe cognitive impairment and other health issues, did not receive his scheduled shower on May 28, 2024. His care plan also required partial assistance with bathing three times a week. Interviews with staff revealed that due to staffing shortages, Resident #2 missed his shower, and there was no documentation to indicate that the shower was rescheduled or completed. The staff's inability to provide the necessary care due to understaffing was a significant factor in this deficiency. The facility's documentation practices were inadequate, as evidenced by the lack of shower sheets and updates in the resident information database. Interviews with staff, including CNAs and the DON, revealed inconsistencies in communication and documentation, contributing to the failure to provide scheduled showers. The facility's policy on activities of daily living emphasized the importance of maintaining residents' hygiene, but the observed practices did not align with these standards, resulting in potential risks for the residents involved.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that Resident #4, who required total assistance during feedings, received food that accommodated her preferences. Resident #4, an eighty-one-year-old woman with diagnoses including hemiplegia, hemiparesis, dysphagia, and dementia, was served cold food during mealtimes. Her care plan indicated she required substantial assistance to eat and g-tube feeding. Interviews with residents revealed that there was often only one aide available to feed multiple residents, resulting in delays that caused the food to become cold. Resident #4 confirmed that while her food was delivered hot, it was often cold by the time she was fed, and she would only have it warmed up upon request. The issue was corroborated by another resident who observed that Resident #4's food had sat for up to 30 minutes before being served. The Assistant Director of Nursing (ADON) acknowledged that residents requiring feeding assistance were receiving cold food and agreed that staff should warm up meals if necessary. The facility's policy on Resident Rights emphasized treating residents with kindness, respect, and dignity, but no specific dietary policy was reviewed. This deficiency highlights a failure to meet resident preferences and ensure meals are served at an appetizing temperature.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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