Heritage House Of Marshall Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshall, Texas.
- Location
- 5915 Elysian Fields Road, Marshall, Texas 75672
- CMS Provider Number
- 676187
- Inspections on file
- 36
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage House Of Marshall Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of CVA, hemiplegia, and hyperlipidemia did not receive a scheduled Repatha injection when due, after the family-supplied medication was not available on time due to weather. The assigned LVN marked the dose as not given but did not document the reason on the MAR or notify the MD, despite facility policy requiring documentation and physician notification when medications are held. The DON confirmed the missed dose and that the issue was only identified after the resident reported the omission.
A deficiency was identified when a resident with significant mobility and cognitive impairments was transferred by a CNA without the required two-person assist, due to discrepancies and confusion in the care plan and kardex documentation. Staff interviews revealed inconsistent understanding of the resident's transfer needs, and the care plan was not properly updated, leading to improper implementation of safe transfer procedures.
Two residents with cognitive and physical impairments were not treated with dignity and respect by a CNA, who was reported to have spoken to them in a verbally rough and condescending manner. One resident expressed fear and emotional distress due to the CNA's approach during care, while a family member of another resident confirmed similar experiences. Staff interviews corroborated concerns about the CNA's attitude and communication with residents.
A nurse was found in possession of a resident's prescribed Promethazine-Dextromethorphan outside the facility, after law enforcement discovered the medication during a traffic stop. The resident, who had severe cognitive impairment and multiple medical conditions, was prescribed the medication for nausea via gastrostomy. The facility could not account for the medication's storage prior to the incident, and the nurse was terminated for violating the facility's code of conduct.
A staff member failed to immediately report an allegation that a CNA used verbally abusive language toward a resident with dementia and incontinence, despite facility policy and training requiring prompt reporting of suspected abuse. The incident was not brought to the attention of the DON or Administrator, and the resident's care plan included interventions for incontinence and resistive behaviors.
A facility failed to reconcile controlled medications for four residents, leading to discrepancies in medication counts. An LPN did not immediately document the administration of hydrocodone-acetaminophen, Tylenol #3, and lorazepam, resulting in missing pills. The oversight was acknowledged by the ADON and Administrator as a risk for medication errors and drug diversion.
A resident with dementia and diabetes was not properly assessed for skin and wounds upon readmission, leading to a new Stage III pressure injury. The facility failed to follow wound care recommendations, notify the dietician, and order supplements. A urine-soaked brief was placed over a newly dressed wound, compromising care. Lack of communication and coordination among staff contributed to the deficiency.
The facility failed to address and resolve grievances from residents regarding inconsistent ice passes, staff not responding to call lights, and staff being on phones during care. Despite previous in-services, these issues persisted, with residents having to assist each other. Interviews with staff revealed a lack of awareness of these ongoing problems, indicating a failure in the grievance process.
The facility failed to ensure accurate MDS assessments for four residents, leading to deficiencies in documenting anxiety, dialysis, vision impairment, and a fall. These inaccuracies could affect care planning and billing, as the MDS is crucial for determining resident care needs.
The facility failed to document post-dialysis assessments for two residents and lacked communication records for another, risking unmonitored complications. Despite care plans and orders for regular dialysis, necessary documentation was incomplete, as confirmed by staff interviews.
A resident did not receive prescribed medications for seizures, hypertension, and nausea over three days due to a pharmacy transition issue. The facility faced challenges with medication ordering during a change of pharmacy ownership, leading to unavailable medications and missed doses. The DON and ADM were not informed of the missed doses, contrary to facility policy.
The facility failed to implement isolation precautions for two residents with ESBL in their urine, despite positive culture results. Both residents, one with chronic kidney disease and Type 2 diabetes, and the other with dementia and Type 2 diabetes, were not placed on contact isolation as required by the facility's infection control policies. Interviews with staff revealed a lack of awareness and communication regarding the need for isolation, leading to a deficiency in infection prevention and control.
The facility failed to provide two residents with the necessary NOMNC and SNF ABN notices, which are crucial for informing them about their Medicare/Medicaid coverage and potential liabilities. The social worker admitted to not delivering these notices due to a change in responsibility, leaving the residents uninformed about their healthcare plans.
A facility failed to coordinate PASRR assessments for a resident with multiple diagnoses, including PTSD and bipolar disorder. The resident was not accurately assessed through PASRR Level 1 and 2 screenings, and subsequent MDS assessments showed incomplete evaluations. Staff interviews revealed confusion and lack of access to the PASRR system following a change in facility ownership, leading to deficiencies in care planning and service provision.
The facility failed to ensure accurate PASRR evaluations for two residents with mental illness and intellectual disabilities, leading to potential loss of necessary services. One resident's major depressive disorder was not marked on the PASRR Level 1, and another resident's evaluation incorrectly indicated no mental illness or developmental disability despite having bipolar disorder and cerebral palsy. The errors were acknowledged by the MDS nurse, DON, and Administrator.
The facility failed to develop and implement baseline care plans within 48 hours for two residents, one with chronic atrial fibrillation and mild cognitive impairment, and another with Alzheimer's and other conditions. Both residents did not receive timely care plans, and there was no evidence that copies were provided to them or their representatives. Staff interviews revealed confusion about the process and importance of timely completion, impacting resident care and communication.
A resident with severe cognitive impairment and a PEG feeding tube was observed without the required abdominal binder, a care plan intervention to prevent tube dislodgement. Facility staff confirmed the oversight, acknowledging the risk of the tube being dislodged, which could necessitate surgical replacement and pose additional health risks.
A resident was discharged without a completed discharge summary, which should have included diagnoses, treatment course, and lab results. The social worker started the summary, but it was the nursing staff's responsibility to complete it. The DON acknowledged her responsibility in ensuring its completion, but the summary was unlocatable at the time of discharge.
A resident with Alzheimer's disease was not provided with necessary personal hygiene services, specifically the removal of unwanted facial hair, despite expressing embarrassment and a desire for its removal. Observations and interviews revealed that CNAs did not adhere to the facility's policy on shaving, which should be part of daily hygiene. The LVN and DON confirmed the oversight, highlighting it as a dignity issue.
The facility failed to provide protective smoking aprons to residents who required them during a smoke break, as per their care plans and assessments. Observations and interviews revealed inconsistencies in apron use, with staff admitting to forgetting to apply them. This deficiency was noted in residents with severe cognitive impairment, cerebrovascular disease, and dementia, placing them at risk of burns or injuries.
A resident with Alzheimer's and bladder dysfunction was not provided appropriate care for her indwelling catheter. Despite a physician's order to consult a urologist for catheter removal and bladder retraining, the facility failed to follow through. The LVN did not place the order or follow up with the urologist, and the DON was unaware of the situation. The resident was distressed by the catheter, which was leaking, and expressed concerns about infection risk.
A resident was prescribed antibiotics for a UTI despite urine culture results showing no organism growth. The facility failed to communicate these results to the physician, leading to unnecessary antibiotic use. Interviews revealed a lack of documentation and communication, contrary to the facility's Antimicrobial Stewardship policy.
A facility failed to review and discontinue a PRN lorazepam order for a resident after 14 days, as required by policy. The resident, who had diagnoses including anemia, atrial fibrillation, and depression, was on both Clonazepam and lorazepam for panic disorder. The lorazepam PRN order was used several times in May but not in June. Interviews with the MD and DON indicated a lack of oversight regarding the continuation of the PRN order, which was almost two months old and still active.
A resident in a LTC facility missed doses of Levetiracetam due to pharmacy transition issues, leading to significant medication errors. The facility experienced communication breakdowns and ordering difficulties, resulting in the resident not receiving his seizure medication as prescribed. Staff interviews revealed a lack of awareness and communication about the missed doses, contrary to the facility's policy of timely medication reordering.
The facility failed to have a certified Activity Director (AD) to lead its activities program, as required by regulations. The current AD, employed since December 2024, was not certified and had not received guidance from a certified AD. Interviews with staff confirmed the absence of a certified AD for at least six months, posing a risk to residents' activity needs.
The facility failed to transmit MDS assessments for 16 residents within the required 14-day period due to a management change that delayed access to the transmission portal. The MDS nurse, responsible for the transmission, was unable to submit the assessments on time, potentially affecting the facility's quality measures and leading to penalties.
A facility failed to implement its abuse prevention policies when a resident accused a CNA of rough handling. Despite the facility's policy requiring immediate suspension of the alleged perpetrator, the CNA was not suspended until two days later due to miscommunication. The resident's family reviewed video footage and expressed concerns, but the CNA was only reassigned, not suspended. This delay in action could have placed residents at risk for continued abuse.
A resident accused a CNA of rough handling and disrespect, but the facility failed to report the abuse allegation to the state agency within the required 24-hour timeframe. The CNA was not suspended until two days later, as the administrator was not initially informed of the specific allegations. This delay violated the facility's policy and could risk continued abuse.
A resident with a fractured leg and Foley catheter was improperly transferred by a single CNA using a mechanical lift, despite the care plan requiring two staff members. The CNA, pressured by the resident's family, did not check the Kardex and proceeded alone, resulting in the catheter dislodging and causing pain. Facility policy and FDA guidelines both mandate two-person assistance for such transfers.
A resident's medications were not properly reconciled during both admission and discharge. LVN A did not complete the required documentation upon admission, and LVN B failed to ensure the family signed for the medications upon discharge. The family later reported missing medications, and the facility could not find any documentation to support proper reconciliation.
Failure to Administer and Properly Manage Ordered Repatha Injection
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for a resident receiving Repatha injections for hyperlipidemia. The resident, an older adult female with a history of CVA, hemiplegia, and hyperlipidemia, had an order and care plan interventions for Repatha 140 mg/mL subcutaneous every two weeks. Review of the January MAR showed the Repatha dose due on 01/26/2026 was not administered by the assigned LVN, despite the standing order. The resident reported she missed her cholesterol injection at the end of January, that no one contacted the MD, and that her family brought the medication to the facility the day after it was due. The LVN acknowledged missing the Repatha injection scheduled for 10:00 a.m. on 01/26/2026, stating the family supplied the medication and could not bring it on time due to weather, and that she marked the dose as not given but did not document the reason for the missed dose on the MAR or notify the MD. She also stated she was unaware she needed to call the MD when a medication was unavailable. The DON confirmed the resident missed the injection because the family could not bring the medication during an ice storm and that it had been arranged prior to admission for the family to supply the drug due to cost. The DON further stated the nurse did not notify anyone that the medication was held and that the issue came to light only after the resident complained about the missed dose. Facility policy on medication administration required that whenever a medication is held, the nurse must circle initials on the MAR, document the reason on the back of the MAR, and notify the physician, which did not occur in this case.
Failure to Implement Accurate and Consistent Care Plan for Resident Transfers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to meet a resident's medical and nursing needs. The care plan for a resident with cerebral palsy, repeated falls, impaired cognition, and other significant health issues did not consistently reflect the required level of assistance for transfers. Documentation discrepancies existed between the care plan and the kardex, with conflicting information about whether the resident required a one-person or two-person assist for transfers. This inconsistency led to confusion among staff regarding the appropriate transfer method. On the day of the incident, a CNA attempted to transfer the resident from a shower chair to a wheelchair alone, despite the care plan indicating a two-person assist was required. Another CNA observed the transfer, noted the resident was sliding down, and assisted in lowering the resident to the floor before notifying the charge nurse. Interviews with staff revealed that information about transfer assistance was available in the electronic health record and kardex, but there was uncertainty and lack of clarity due to the conflicting care plans. Some staff relied on word of mouth or their own judgment rather than consistently referencing the care plan. Further interviews and record reviews confirmed that the care plan had not been properly updated or resolved, resulting in staff not having accurate or consistent guidance on the resident's transfer needs. The MDS nurse acknowledged the error in documentation and the negative impact of an incorrect care plan, while the DON and administrator confirmed that staff were expected to follow the care plan and that discrepancies could lead to inadequate care. The facility's policies required comprehensive care planning and safe transfer procedures, but these were not effectively implemented in this case.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights regulations. One resident, a female with vascular dementia, agitation, and major depressive disorder, reported to the DON and ADON that she was afraid of a CNA, stating the CNA was mean to her and did not like her. The resident described an incident where the CNA dressed her in a manner different from other staff and expected her to assist, which made her uncomfortable. During an interview, the resident further stated that the CNA was verbally rough, telling her to stand up and that she could do things herself, which hurt her feelings and made her cry. The resident indicated that this verbal treatment occurred often and made her reluctant to get up when the CNA was working her hall. A second resident, a male with muscle wasting, vascular dementia, cerebral infarction, and hemiplegia, was also identified as having received care in a disrespectful manner. A family member, who resided in the same room, reported hearing the same CNA speak roughly or meanly to both residents, expressing that the CNA seemed irritated and tired when providing care. The family member stated that this behavior had occurred repeatedly over the past three months and that she dreaded when the CNA was assigned to care for her family member. The resident himself nodded in agreement with the family member's statements about the CNA's conduct. Interviews with other staff provided additional context, with one staff member describing the CNA as speaking to residents in rude and condescending ways and talking about residents in their presence. The staff member felt the CNA seemed overworked and took out her frustrations on the residents. The DON and Administrator confirmed that the resident had reported the incident and that the CNA was suspended pending investigation. The facility's policy affirms the right of residents to a dignified existence and to be treated with respect and dignity.
Misappropriation of Resident Medication by LVN
Penalty
Summary
A deficiency occurred when a nurse (LVN) was found in possession of a resident's prescribed medication, Promethazine-Dextromethorphan, outside of the facility. The medication, which was ordered to be administered via gastrostomy as needed for nausea, was discovered during a traffic stop by local law enforcement. The bottle was labeled with the resident's name and was found in the LVN's personal bag. The LVN was unable to provide a satisfactory explanation for how the medication ended up in her possession. The resident involved was a male with significant medical conditions, including cerebral infarction, hemiplegia, hemiparesis, type 2 diabetes, epilepsy, and a gastrostomy. He had severely impaired cognition, as indicated by a BIMS score of 00, and his care plan included interventions for impaired cognitive function and medication administration as ordered. However, the care plan did not specifically address the use of Promethazine-Dextromethorphan Syrup. Prior to the incident, the facility did not have clear documentation of where the resident's medication was stored, with reports indicating it could have been kept in either the medication cart or the resident's room. The incident was reported to the facility by the county sheriff's office, and subsequent interviews with facility leadership confirmed that the LVN had no prior disciplinary issues or suspicious behavior reported. The facility was unaware of the medication's whereabouts prior to the incident and had to reorder the missing medication. The LVN was terminated for failing to adhere to the corporate code of conduct after being found with the resident's medication outside the facility.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by regulation. Specifically, a staff member (Confidential Staff C) witnessed another staff member (CNA B) allegedly call a resident 'pissy and smelly' during a heated argument but did not report the incident to the Administrator or Abuse Coordinator. Confidential Staff C stated that previous reports to administration about CNA B had not resulted in action, which contributed to the failure to report this new allegation. The facility's policy requires immediate verbal reporting of suspected abuse to the Abuse Preventionist or designee, but this procedure was not followed in this instance. The resident involved was an elderly female with diagnoses including dementia, hypertension, and chronic obstructive pulmonary disease. Her quarterly MDS assessment indicated she was usually understood and had intact cognition, with a BIMS score of 15. She required moderate assistance for toileting hygiene and was frequently incontinent. Her care plan included interventions for incontinence and resistive behaviors, with specific instructions for staff to report incidents of care refusal to the charge nurse. Interviews with facility leadership, including the DON and Administrator, confirmed that the alleged verbal abuse was never reported to them. Both emphasized the importance of immediate reporting to protect residents and stated that the facility provided regular in-services on abuse prevention and reporting. The resident herself did not recall any staff making mean comments, but the failure to report the allegation as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate reconciliation of controlled medications for four residents. Licensed Vocational Nurse (LVN) A did not reconcile the administration of hydrocodone-acetaminophen for three residents and Tylenol #3 and lorazepam for another resident on the Medication Administration Record (MAR) and the individual control drug record after the medications were given. This oversight was observed during a survey conducted on January 28, 2025. Resident #1, a male with a history of lower back injuries, received hydrocodone-acetaminophen for pain management. However, the individual control drug record indicated a discrepancy of one pill. Similarly, Resident #2, a female with dementia and a broken femur, also had a discrepancy of one pill in her hydrocodone-acetaminophen count. Resident #3, a male with chronic pain and anxiety disorder, had discrepancies in both Tylenol #3 and lorazepam counts, with one pill missing from each medication. Resident #4, a male with a broken lumbar vertebra, also had a discrepancy of one pill in his hydrocodone-acetaminophen count. During interviews, LVN A admitted to administering the medications but failed to sign them out immediately, intending to do so later. This practice was acknowledged as a mistake by LVN A and was recognized by the Assistant Director of Nursing (ADON) and the Administrator as a risk for medication errors and drug diversion. The facility's policies require immediate documentation of administered medications to prevent such discrepancies.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident, leading to a deficiency. The resident, who was readmitted to the facility with a history of dementia, Type 2 Diabetes Mellitus, and heart disease, was not properly assessed for skin and wounds from the time of readmission. A new Stage III pressure injury was identified on the resident's right lateral glute, which had not been previously documented or treated. Additionally, the facility did not follow the wound care recommendations from the wound care physician for existing wounds on the sacrum and left foot. The facility's inaction included not notifying the dietician of the resident's wounds and failing to order necessary supplements to promote wound healing. Furthermore, there was an incident where a urine-soaked brief was placed over a newly dressed wound, compromising the wound care process. The lack of proper skin assessments and wound care documentation contributed to the oversight and mismanagement of the resident's condition. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's wound care. The admitting nurse did not complete a skin assessment upon the resident's readmission, and there was a failure to restart previous wound care orders. The facility also lacked a full-time treatment nurse, which placed the responsibility of wound care on charge nurses, leading to inconsistencies in care delivery. These actions and inactions resulted in the identification of an Immediate Jeopardy situation, highlighting the facility's failure to adhere to professional standards of practice in wound management.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to consider and act promptly upon the grievances and recommendations of resident or family groups concerning issues of resident life in the facility. This deficiency was identified for seven anonymous residents who had voiced grievances that were not adequately addressed. The grievances included inconsistent ice passes, staff talking about personal matters in hallways, and issues with shower schedules. Additionally, residents reported that staff would turn off call lights without returning to fulfill requests, leading to residents having to assist each other. During a confidential resident group interview, attendees reiterated grievances that had been previously addressed but continued to occur. These included staff not filling water and ice, requiring residents to get their own water, ice, and snacks, and staff not responding to call lights in a timely manner. Residents also reported that staff were on their phones during resident care. Interviews with staff members, including CNAs, the SW, LVN, ADON, DON, and ADM, revealed a lack of awareness or acknowledgment of these ongoing issues, despite previous in-services and discussions. The facility's policy on grievances, dated November 2024, outlines the residents' right to voice grievances without fear of reprisal and the facility's obligation to resolve these grievances promptly. However, the facility failed to follow up and monitor previous grievances effectively, as evidenced by the repeated concerns voiced by residents. The facility's grievance process, overseen by the administrator or their designee, was not adequately implemented, leading to unresolved resident concerns and dissatisfaction.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for four residents, leading to deficiencies in their Minimum Data Set (MDS) documentation. Resident #30's MDS did not reflect her diagnosis of generalized anxiety disorder, despite it being documented in her care plan. This oversight could potentially affect the resident's care plan and the facility's billing, as the MDS is a critical component in determining the care needs and services provided to residents. Resident #36's MDS did not indicate his dialysis status, even though he was receiving hemodialysis three times a week as documented in his care plan and dialysis communication records. This omission in the MDS could lead to inadequate care planning and affect the facility's billing processes. Similarly, Resident #45's MDS failed to reflect his vision impairment due to glaucoma, which was noted in his care plan. This discrepancy could result in the resident not receiving appropriate assistance for his visual needs. Additionally, Resident #212's MDS did not document a fall that occurred, as recorded in the facility's incident report and her care plan. The MDS coordinator acknowledged these inaccuracies and emphasized the importance of accurate MDS documentation for resident care planning and facility billing. The Director of Nursing and the Administrator also recognized the responsibility of the MDS coordinator in ensuring accurate assessments, highlighting the potential risks of inaccurate MDS documentation on resident care and facility operations.
Inadequate Documentation of Dialysis Care
Penalty
Summary
The facility failed to ensure that dialysis services were provided consistently with professional standards of practice for three residents who required such services. Specifically, the facility did not complete and document post-dialysis assessments for two residents, and there was a lack of documentation for another resident's dialysis communications. These deficiencies were identified through interviews and record reviews. For Resident #36, the facility's records showed missing or incomplete nurse assessments upon return from dialysis on multiple dates across March, April, and May 2024. This resident, a male with end-stage renal disease, was supposed to receive hemodialysis three times a week. Despite having a care plan and orders for dialysis, the necessary post-dialysis assessments were not consistently documented, which could lead to unmonitored complications. Similarly, Resident #212, a female with chronic kidney disease and other health issues, also had missing or incomplete post-dialysis assessments on several dates. Her care plan required monitoring of vital signs, but the documentation was lacking. Additionally, for Resident #112, there was no communication documented between the facility and the dialysis center, despite the resident receiving dialysis three times a week. Interviews with staff, including the DON and RN, confirmed the importance of these forms for continuity of care and highlighted the risk of unmonitored changes in the residents' conditions due to incomplete documentation.
Medication Administration Failure Due to Pharmacy Transition
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of a resident, identified as Resident #45, who did not receive prescribed medications over a three-day period. The medications not administered included Levetiracetam for seizures, Hydrochlorothiazide for hypertension, and a Scopolamine patch for nausea and vomiting. This lapse occurred due to the facility's inability to maintain an adequate stock of these medications, which was attributed to issues with the pharmacy service during a change of ownership and pharmacy company. Interviews with staff revealed that the nursing team faced challenges in ordering medications through the facility's computer system during the transition to a new pharmacy. The prescription numbers had changed, leading to confusion and duplicate refill orders, which the new pharmacy refused to fill. This lack of communication and coordination among the nursing staff resulted in the resident missing critical doses of medication, placing him at risk for seizures, high blood pressure, and nausea. The Director of Nursing (DON) and the Administrator (ADM) were not informed of the missed doses, which they expected to be notified about. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply, but this procedure was not followed. The ADM emphasized that charge nurses were responsible for ensuring residents received their prescribed medications and that the DON should oversee this process to prevent missed doses.
Failure to Implement Isolation Precautions for Residents with ESBL
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by their handling of two residents with ESBL in their urine. Resident #46, a female with chronic kidney disease and Type 2 diabetes, was not placed on contact isolation despite urine cultures revealing the presence of ESBL. Her care plan noted a history of recurring UTIs, yet there were no isolation orders or documentation of isolation in her records. Similarly, Resident #50, a female with dementia and Type 2 diabetes, also tested positive for ESBL in her urine, but was not placed on contact isolation. Her care plan included interventions for urinary tract infections, but there was no documentation of isolation measures being implemented. Interviews with facility staff revealed a lack of awareness and communication regarding the need for isolation precautions for residents with ESBL. RN E stated that residents with ESBL required contact isolation, and the ADON, who was responsible for infection control, admitted to not being aware of the ESBL results for the two residents. The DON confirmed that the nurse and ICP were responsible for reviewing lab results and ensuring isolation for residents with MDROs, but acknowledged that Resident #46 and Resident #50 were not placed on contact isolation as required. The facility's policies on infection control and isolation precautions were not followed, as evidenced by the lack of isolation for the two residents with ESBL. The facility's Infection Control Plan and Enhanced Barrier Precautions policy outlined the need for appropriate resident placement and isolation to prevent the spread of infections, but these measures were not implemented for Resident #46 and Resident #50. This oversight in infection control practices could potentially expose other residents and staff to health complications and infectious diseases.
Failure to Provide Required Medicare/Medicaid Notices
Penalty
Summary
The facility failed to inform two residents, Resident #31 and Resident #212, about their Medicare/Medicaid coverage and potential liability for services not covered. This deficiency was identified through interviews and record reviews, revealing that the facility did not provide the necessary Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to these residents. Resident #31, a female with diagnoses including congestive heart failure and Type 2 diabetes, was not given the required notices when her Medicare Part A skilled services were discontinued before exhausting her covered days. Similarly, Resident #212, a female with conditions such as pulmonary embolism and chronic kidney disease, did not receive these notices when her Part A services were terminated. The social worker (SW) responsible for delivering these notices admitted to failing to provide the NOMNC and SNF ABN forms to the residents. The SW explained that under the previous company, she was responsible for both forms, but with the current company, her responsibility was limited to NOMNCs, while the MDS coordinator was to handle the ABNs. The SW acknowledged the importance of delivering these notices timely to allow residents to make informed decisions about their healthcare and to be aware of their plan of care. The SW also noted that failing to deliver these notices could leave residents feeling surprised and helpless. The facility's policies and procedures for delivering NOMNC and ABN notices were reviewed, indicating that these notices must be provided at least two days before the end of Medicare-covered services. However, the facility did not adhere to these policies, as evidenced by the lack of documentation in the residents' medical records. The administrator confirmed the change in responsibility for delivering these notices and emphasized the importance of providing them to ensure residents are informed about their care plans.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident, leading to a deficiency in the screening process. The resident, a female with multiple diagnoses including hemiplegia, Type II Diabetes, acute kidney failure, PTSD, and bipolar disorder, was not accurately assessed through the PASRR Level 1 and 2 screenings. The initial admission MDS indicated that the resident was not considered to have a serious mental illness, despite having active diagnoses of depression, bipolar disorder, and PTSD. Subsequent MDS assessments showed that the resident was unable to complete the BIMS assessment, yet the care plan did not reflect a PASRR 1 screening. Interviews with facility staff revealed a lack of access to PASRR screenings following a change in facility ownership, which resulted in the loss of necessary passwords. The MDS nurse, who had been at the facility for about a month, reported that she did not have access to the PASRR system and was unaware if the resident was receiving outpatient services. The social worker and ADON also expressed confusion about their roles in the PASRR process, with the social worker stating that the MDS nurse was responsible for PASRR and the ADON indicating a lack of knowledge about the process. The Director of Nursing (DON) acknowledged the expectation for PASRR completion but noted issues with transmission due to the facility's recent purchase. The DON confirmed that the facility was not currently addressing the needs of PASRR-positive residents. The Administrator emphasized the importance of capturing psychiatric diagnoses accurately for care planning, yet the facility's policy on PASRR evaluations was not being followed, as evidenced by the lack of timely and accurate screenings for the resident in question.
Failure to Conduct Accurate PASRR Evaluations
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness and intellectual disabilities received the necessary PASRR Evaluation assessments. This deficiency was identified for two residents, one with a serious mental illness and another with developmental disability and mental illness. The facility did not coordinate with the Local Intellectual/Developmental Disability and/or Local Mental Health Authority to conduct accurate PASRR Level I and Level II Evaluations for these residents. For the first resident, the facility did not mark the diagnosis of major depressive disorder on the PASRR Level 1, which was necessary for the resident to be considered PASRR positive. The MDS nurse responsible for entering PASRR information admitted that the original submission was not followed up, resulting in the PASRR remaining in invalid status until it was resubmitted months later. The Director of Nursing (DON) and the Administrator acknowledged that the mental illness should have been marked on the PASRR Level 1, and the failure to do so meant the resident did not receive specialized services. The second resident's PASRR Level 1 Evaluation incorrectly indicated that the resident did not have a mental illness, intellectual disability, or developmental disability, despite having diagnoses of bipolar disorder and cerebral palsy. The MDS Coordinator, who began working at the facility after the initial evaluation, discovered the mistake during an audit but was unable to request a new evaluation due to access issues. The DON and Administrator both recognized that the resident should have been PASRR positive and that the incorrect evaluation could have prevented the resident from receiving necessary services.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for two residents. Resident #163, an 86-year-old female with chronic atrial fibrillation, hypertension, and mild cognitive impairment, did not have a baseline care plan completed until several days after her admission. Despite documentation indicating that a copy of the baseline care plan was given to her, Resident #163 reported not having any meetings regarding her care or receiving a copy of her care plan. Similarly, Resident #213, who has Alzheimer's disease, retention of urine, overflow incontinence, hypertension, and spinal stenosis, did not have a baseline care plan initiated within the required timeframe. The care plan was started more than 48 hours after her admission, and there was no evidence that a copy was provided to her or her representative. Interviews with the resident and attempts to contact her representative were unsuccessful in confirming receipt of the care plan. Interviews with facility staff revealed a lack of understanding and adherence to the policy requiring baseline care plans to be completed within 48 hours. The charge nurse, social worker, and MDS nurse were identified as responsible for initiating and completing the care plans, but there was confusion about the process and the importance of timely completion. The Director of Nursing and Administrator acknowledged the oversight and the potential impact on resident care and communication.
Failure to Implement Care Plan for Resident with PEG Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not ensure that a resident's care plan intervention of wearing an abdominal binder over his PEG feeding tube was followed. This oversight was observed when the resident was seen without the abdominal binder, which was intended to protect the PEG tube from being dislodged. The resident, a male with severe cognitive impairment and a history of nontraumatic intracerebral hemorrhage and dysphagia, was known to pull out his feeding tube and move the abdominal binder. Despite this, the resident was observed without the binder, risking the dislodgement of the PEG tube. Interviews with facility staff, including an RN, the DON, and the ADM, confirmed that the care plan intervention was not followed, which could lead to the PEG tube being dislodged, requiring surgical replacement, and risking missed feedings, trauma, and infection.
Missing Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a resident had a discharge summary that included a recapitulation of the resident's stay, which is necessary for a smooth transition of care. The resident, an elderly female with diagnoses including sepsis, hypertension, and anxiety, was discharged home with home health services, physical therapy, and medications. However, the discharge summary, which should have included diagnoses, course of illness/treatment, and pertinent lab, radiology, and consultation results, was not completed or was unlocatable at the time of discharge. Interviews with facility staff revealed that the social worker began the discharge summary, but it was the responsibility of the nursing staff to complete it. The Director of Nursing acknowledged that it was her responsibility to ensure the discharge summary was completed, and the charge nurse was supposed to provide the resident with a medication review and remaining medications at discharge. Despite these procedures, the discharge summary for the resident was missing, and the facility's administrator and staff were unsure why it was unlocatable.
Failure to Provide Personal Hygiene Services
Penalty
Summary
The facility failed to provide necessary personal hygiene services for a resident, specifically in the removal of unwanted facial hair. The resident, a female with Alzheimer's disease, was admitted to the facility less than 21 days prior to the survey. Observations and interviews revealed that the resident had medium blonde hair on her chin, which she found embarrassing and expressed a desire to have removed. Despite having received a shower, the resident's facial hair was not addressed, and the aides responsible did not ensure its removal. Interviews with the CNAs and LVN indicated a lack of adherence to the facility's policy on shaving, which states that facial hair should be removed as part of daily personal hygiene. The CNAs acknowledged their responsibility to remove facial hair during showers or bed baths, but failed to do so. The LVN and DON confirmed that the charge nurse should ensure the removal of facial hair, and that the failure to do so was a dignity issue for the resident. The facility's policy emphasized the importance of shaving for cleanliness and a positive body image, yet this was not followed in the case of the resident.
Failure to Provide Protective Smoking Aprons
Penalty
Summary
The facility failed to ensure that residents who smoked were provided with protective smoking aprons, as required by their care plans and smoking assessments. This deficiency was observed during a smoke break where three residents, who were identified as needing protective aprons, were seen smoking without them. These residents included a 63-year-old male with severe cognitive impairment, a male with cerebrovascular disease and hemiplegia, and a female with dementia and chronic kidney disease. Each of these residents had specific care plan interventions that required the use of a fire-resistant smoking apron while smoking. Interviews with staff and residents revealed inconsistencies in the application of the smoking aprons. A housekeeper admitted to forgetting to put the aprons on the residents during the observed smoke break. Additionally, one resident reported that the use of aprons varied depending on which staff member was supervising the smoke break. This inconsistency was further evidenced by a burn hole observed on the clothing of one resident, who admitted to dropping ashes on his lap while not wearing an apron. The facility's Director of Nursing (DON) and Administrator acknowledged the responsibility of staff to ensure residents wore protective aprons during smoke breaks. The facility's smoking policy, which was reviewed, outlined the requirement for smoking assessments and the use of protective devices for residents identified as needing them. However, the failure to consistently enforce this policy led to the observed deficiency, placing residents at risk of burns or injuries.
Failure to Follow Physician's Orders for Catheter Removal
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and had an indwelling catheter. The resident, a female with Alzheimer's disease and neuromuscular dysfunction of the bladder, was admitted to the facility with a catheter. Despite a family request and a physician's order to consult a urologist for the removal of the catheter and bladder retraining, the facility did not follow through with the necessary actions. The resident's family expressed concerns about her dependency on the catheter and its impact on her behavior. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not place the order to consult the urologist as instructed by the physician. Although the LVN contacted the urologist's office, she did not leave a message or follow up as required. This oversight was not documented in the resident's progress notes, and the Director of Nursing (DON) was unaware of the situation due to being at a conference. The failure to act on the physician's order and the lack of communication and documentation placed the resident at risk for infection and discomfort. Observations revealed that the resident was visibly upset and anxious about her catheter, which was leaking and causing distress. The resident expressed concerns about the risk of bladder infection and discomfort with the catheter. The facility's policies on catheter use and physician's orders were not adhered to, leading to a deficiency in the care provided to the resident.
Failure to Discontinue Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically antibiotics, which is a violation of pharmacy services standards. A resident, who was admitted with diagnoses including Parkinson's disease, sepsis, and acute kidney failure, was prescribed Keflex for a urinary tract infection (UTI) despite urine culture results showing no organism growth. The resident's medical records indicated that the antibiotic was administered for seven days based on initial urinary analysis results, which showed abnormal leukocyte esterase and a positive catalase bacteria screen, but the subsequent urine culture did not detect any pathogens. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's urine culture results. The RN responsible for lab results stated that results were typically faxed to the doctor, but there was no documentation proving that the negative culture results were communicated to the physician. The Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist, acknowledged that the facility's policy required antibiotics to be discontinued if no organism growth was detected, but she believed the physician decided to continue the antibiotics. The Director of Nursing (DON) confirmed that there was no evidence in the resident's chart that the physician was notified of the negative culture results. Further interviews with the facility's staff and the medical assistant from the physician's office indicated that only the initial urinary analysis results were sent to the physician, leading to the prescription of antibiotics. The facility's Antimicrobial Stewardship policy emphasized the importance of communicating culture and sensitivity results to determine the necessity of continuing antibiotic therapy. However, the lack of documentation and communication led to the continuation of unnecessary antibiotic treatment for the resident, contrary to the facility's policy and best practices for antibiotic stewardship.
Failure to Review and Discontinue PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive psychotropic drugs pursuant to a PRN order unless the medication was necessary to treat a diagnosed specific condition documented in the clinical record. The PRN orders for psychotropic drugs were not limited to 14 days as required. Specifically, the facility did not discontinue or review the PRN lorazepam order for a resident after 14 days, nor did a physician document the rationale for extending the usage beyond this period. The resident involved was an elderly female with diagnoses including anemia, atrial fibrillation, and depression. She was unable to complete the BIMS assessment and required substantial assistance for ADL care. The resident had orders for Clonazepam and lorazepam for panic disorder, with the lorazepam PRN order being used multiple times in May but not in June. Interviews with the MD and DON revealed a lack of awareness and oversight regarding the continuation of the PRN lorazepam order, which was almost two months old and still active, contrary to the facility's policy.
Medication Error Due to Pharmacy Transition
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Levetiracetam, a medication used to treat seizures. The resident, a male with a history of nontraumatic intracerebral hemorrhage and convulsions, was not administered his prescribed doses of Levetiracetam on two consecutive days. The medication was to be given twice daily via g-tube, but records indicated that it was unavailable on those days. Interviews with nursing staff revealed that the facility was experiencing issues with medication ordering due to a change in pharmacy ownership, which led to communication breakdowns and difficulties in ordering medications. The Director of Nursing (DON) and other staff were not aware of the missed doses, and there was a lack of communication regarding the medication unavailability. The facility's policy required medications to be reordered three to four days in advance, but this was not adhered to, resulting in the resident missing critical doses of his seizure medication. The absence of the medication placed the resident at risk for seizures and other health complications, as acknowledged by the nursing staff and administration during interviews.
Facility Lacks Certified Activity Director
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by regulations. The Activity Director (AD) at the facility was not certified, and there was no certified AD on staff or a corporate AD available. The AD had been employed since December 2024 and had previously worked as an activity director assistant and at an assisted living facility. Despite her experience, she lacked the necessary certification to fulfill the role of AD. The facility had not had a certified AD for at least six months, and the current AD was scheduled to take her certification test soon. Interviews with facility staff, including the Administrator (ADM), Human Resources (HR) Coordinator, and Director of Nursing (DON), confirmed the absence of a certified AD. The ADM acknowledged the importance of having a certified AD to provide appropriate activities and engage residents effectively. The AD herself admitted to not having guidance from a certified AD and not documenting one-on-one activities until the new company took over. The lack of a certified AD was noted as a potential risk for residents not receiving a program of activities that meets their assessed needs.
Delayed MDS Transmission Due to Management Change
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for 16 residents were transmitted to the CMS System within the required 14-day period following the completion of the assessments. This deficiency was identified through interviews and record reviews, which revealed that the MDS assessments for various residents, including discharge, comprehensive, and quarterly assessments, were not transmitted as required. The delay in transmission was attributed to a change in the facility's management, which resulted in the MDS nurse not having access to the transmission portal necessary for submitting the assessments on time. Interviews with the MDS nurse and the Director of Nursing (DON) highlighted that the responsibility for MDS transmission lay with the MDS nurse, under the oversight of the regional MDS nurse. The facility's administrator acknowledged the issue, noting that the management change had delayed access to the transmission portal, potentially affecting the facility's quality measures and leading to monetary penalties. The CMS RAI Version 3.0 Manual specifies that MDS assessments must be encoded within 7 days and transmitted within 14 days, a requirement that the facility failed to meet due to the management transition.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and mistreatment of residents, as evidenced by the handling of an allegation involving a resident and a CNA. The resident, who had a history of making false accusations, reported that the CNA had a bad attitude and was rough during care. Despite the facility's policy requiring immediate suspension of an alleged perpetrator pending investigation, the CNA was not suspended until two days after the initial report. This delay in action was due to a miscommunication or misunderstanding of the severity of the allegations by the facility's administrator. The resident's family member reviewed video footage from the resident's room and felt that the CNA was acting erratically and roughly during care. The family member communicated these concerns to the facility staff, requesting the removal of the CNA from the resident's care. Despite these concerns, the CNA was only moved to a different hallway and not suspended immediately, as required by the facility's policy. The administrator was informed of the situation but did not perceive the allegations as serious enough to warrant immediate suspension until later. The facility's failure to adhere to its policy of immediate suspension and timely reporting to HHSC could have placed residents at risk for continued abuse and neglect. The administrator acknowledged that had the severity of the allegations been communicated clearly, the CNA would have been suspended immediately, and the incident reported to HHSC within the required timeframe. This oversight highlights a breakdown in communication and adherence to established procedures designed to protect residents from potential harm.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required 24-hour timeframe to the state agency. The incident involved a resident who accused a Certified Nursing Assistant (CNA) of having a bad attitude and handling her roughly during care. The resident, who had a history of making false accusations, reported feeling disrespected and physically mishandled by the CNA. Despite the resident's complaints being communicated to the facility's staff, the allegation was not reported to the state agency in a timely manner. The facility's policy required immediate suspension of the employee involved and reporting to the Health and Human Services Commission (HHSC) within 24 hours if no serious bodily injury occurred. However, the CNA was not suspended until two days after the initial report, and the incident was not reported to HHSC until the administrator became aware of the specific allegations. The administrator claimed that the initial report did not include details of physical mishandling, which delayed the suspension and reporting process. Interviews with staff revealed that the resident's complaints were communicated to the administrator and other staff members, but the severity of the allegations was not fully conveyed. The CNA continued to work in the facility, albeit on a different hallway, until the administrator reviewed the statements and took action. This delay in reporting and suspension was a violation of the facility's policy and could potentially place residents at risk for continued abuse and neglect.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was transferred using a mechanical hydraulic lift. The resident, who had a fractured right leg and a Foley catheter, was transferred by a single CNA, contrary to the care plan that required two staff members for such transfers. During the transfer, the resident's Foley catheter became dislodged, causing urine to spill and resulting in pain due to the unsupported fractured leg. The incident occurred when the CNA, who was aware of the requirement for two-person assistance, proceeded with the transfer alone due to pressure from the resident's family to hurry. The CNA admitted to not checking the Kardex for the correct procedure and stated that she often had to perform transfers alone due to staffing issues. The resident expressed fear during transfers and noted that they were always conducted by one person, which made it difficult to manage her leg and avoid bumping into things. Interviews with facility staff, including the DON and Administrator, confirmed that the facility's policy required two people for mechanical lift transfers for safety reasons. The DON acknowledged the risks involved in not following this policy, including potential reinjury and catheter dislodgement. The facility's policy and FDA guidelines both emphasize the necessity of two-person assistance to ensure safe transfers and prevent accidents.
Failure to Reconcile Medications During Admission and Discharge
Penalty
Summary
The facility failed to ensure proper reconciliation of medications for a resident during both admission and discharge. Specifically, LVN A did not follow the facility's policy to reconcile medications when the resident was admitted. LVN A admitted the resident and received medications from the family but did not complete the required Release of Responsibility for Medication Form. Instead, LVN A only documented the count of Hydrocodone and placed the rest of the medications in a bag in the medication room without proper documentation. LVN A admitted to not reconciling the medications as per the facility's policy, despite being trained to do so. Similarly, LVN B did not follow the facility's policy when discharging the resident. The family member reported that LVN B did not go over the medications or have them sign any documentation upon discharge. The family later discovered that some medications were missing and reported this to the facility. LVN B claimed to have given the medications to the family and had them sign a Release of Responsibility for Medication Form, but the Director of Nursing (DON) could not find any documentation to support this. The Administrator confirmed that the facility's policy requires all medications to be counted and signed for by the resident or responsible party upon discharge, and acknowledged that LVN B failed to follow this procedure.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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