Heritage Park Rehabilitation And Skilled Nursing C
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 2806 Real St, Austin, Texas 78722
- CMS Provider Number
- 455599
- Inspections on file
- 40
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Heritage Park Rehabilitation And Skilled Nursing C during CMS and state inspections, most recent first.
A resident with dementia, schizophrenia, and impaired mobility was transported to a canceled off-site medical appointment without her required walker and left unsupervised by a facility van driver. The resident was found alone outside the hospital by security, after the facility failed to update the appointment schedule and communicate the cancellation. Facility protocols requiring supervision for such residents were not followed, resulting in a deficiency.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in multiple rooms, including those of residents with severe cognitive impairments and chronic health conditions. Despite frequent spraying by a pest control company, the issue persisted, indicating ineffective treatments. Staff and residents reported sightings, but communication and awareness were lacking, compromising the residents' right to a safe and clean environment.
Surveyors found that the facility failed to maintain proper food storage, labeling, and sanitation practices, including using a cracked ice scoop receptacle, not cleaning the ice machine and stovetop range adequately, and not labeling or dating multiple food items. Some opened products were not refrigerated as required, and food items in storage were not consistently covered, secured, or properly identified.
The facility did not maintain an effective pest control program, resulting in the presence of flies, gnats, and roaches in resident rooms, dining areas, and common spaces. Staff interviews revealed no specific pest control policy, and resident council minutes documented ongoing complaints about infestations. Pest control service records showed treatments were performed, but pests continued to be observed throughout the facility.
Surveyors found that two residents with urinary catheters did not have privacy covers on their catheter bags, causing distress and embarrassment, despite staff training and facility policy requiring covers. Additionally, several residents seated at the same dining tables were not served their meal trays at the same time, leading to discomfort and signs of hunger. Staff interviews confirmed awareness of the policies, but the deficiencies persisted, affecting residents' dignity.
Staff conducted searches of residents' wheelchairs, belongings, and rooms for contraband without obtaining consent, affecting multiple cognitively intact residents. Residents reported feeling embarrassed, harassed, and singled out, with some stating that personal items were taken and given to others. Staff interviews revealed inconsistent practices and a lack of adherence to facility policy, which requires resident consent for searches.
Several residents were found living in unclean and cluttered rooms, with issues such as dirty linens, persistent flies, clutter, and lack of timely cleaning assistance despite repeated requests. Staff interviews confirmed that cleaning requests were not addressed promptly, and residents expressed distress over the unsanitary conditions. Facility policy required daily cleaning and timely response to resident needs, but these standards were not met.
Three residents did not have comprehensive care plans addressing their specific needs, including oxygen therapy, food allergies, dental care, and PTSD-related accommodations. One resident's care plan omitted oxygen use despite physician orders and observed use; another's plan lacked documentation of a food allergy and dental needs, resulting in continued exposure to allergens and missed dental care; and a third resident's PTSD diagnosis and related care preferences were not assessed or included in her plan, with staff unsure of their responsibilities.
Several residents with significant medical and cognitive needs did not receive regular showers as required, despite being scheduled and care planned for assistance with bathing. Documentation inconsistencies and staff interviews revealed that showers were frequently missed or marked as 'not applicable' without clear justification, and residents reported not refusing care. This resulted in poor hygiene and resident dissatisfaction, with some residents filing grievances and reporting the issue to facility leadership.
Three residents with cognitive and physical impairments did not receive individualized or in-room activities as outlined in their care plans, with repeated observations showing them without stimulation or engagement. Despite care plans and facility policy requiring regular 1:1 activities and staff encouragement, these interventions were not consistently provided or documented, as confirmed by staff interviews.
Staff did not consistently follow infection control protocols, including hand hygiene during meal tray distribution and peri care, and failed to provide proper catheter care for a resident. These lapses were observed despite staff being trained and aware of facility policies, and involved residents with significant medical needs.
Five shared rooms were found to have beds with less than the required 80 square feet per resident, with digital measurements confirming that several middle beds in these rooms did not meet regulatory standards. The ADM and DON were unaware of the deficiency and no waivers or variances were in place.
A resident with multiple neurological and psychiatric diagnoses was provided incontinent care without full privacy, as the privacy curtain was only partially closed and the door remained open while a roommate was present. The resident expressed discomfort, and the CNA acknowledged the failure to fully close the curtain, despite facility policy and prior staff training requiring privacy measures during personal care.
A resident was found with triangular wedges on her bed that restricted her movement, despite no medical need, pressure ulcer, or physician order documented. Staff interviews confirmed that wedges should only be used for positioning with a doctor's order, and the facility's policy prohibits restraints for staff convenience. The resident's care plan and medical chart did not include the use of wedges, and staff could not explain their presence.
A resident with a documented diagnosis of PTSD was admitted, but the facility did not include any instructions or interventions for PTSD in the baseline care plan within 48 hours. The resident was not asked about her triggers or preferences, and staff interviews revealed uncertainty about responsibility for updating care plans to address mental health needs.
A resident with cognitive impairment and swallowing difficulties was given a sip of shower gel from an unlabeled cup left in their room, after a family member mistook it for a thickened liquid. The resident immediately spit out the liquid and was assessed by an LVN, with no adverse effects noted. Staff and the DON were unable to determine how the soap ended up in the cup or who placed it there, and the facility's policy requiring a hazard-free environment was not followed.
A resident with PTSD did not have her diagnosis, triggers, or care preferences documented or addressed in her care plan, despite her clear communication of needs such as a preference for female and English-speaking staff. Facility staff were unclear about their responsibilities for trauma-informed care planning, and the facility's policy requiring individualized, trauma-informed, and culturally competent care was not followed.
The facility exceeded the acceptable medication error rate when two residents received medications contrary to physician orders: one was given a whole gel capsule instead of a crushed form, and another received Metoprolol ER despite vital signs outside the prescribed parameters. Both medication aides failed to follow established medication administration protocols.
A staff member administered a blood pressure medication to a resident with severe cognitive impairment, despite the resident's heart rate being below the physician-ordered threshold for administration. The staff member acknowledged the error and facility policy requires holding medications when vital signs are outside prescribed parameters.
Surveyors found that two medication carts were left unlocked and unattended, with one instance involving a medication aide leaving medications out of sight while seeking clarification from a nurse. Staff interviews confirmed knowledge of the policy requiring carts to be locked, but the written policy did not address medication storage.
A resident with multiple medical conditions missed a scheduled MRI appointment because facility staff failed to arrange timely transportation, resulting in the appointment's cancellation. The resident was not informed about the rescheduling or future transportation plans, and staff interviews revealed confusion about transportation procedures and a lack of a formal policy.
A resident with multiple medical conditions missed a dental appointment for denture castings after the facility failed to arrange appropriate transportation. The facility van was unavailable, and the resident was given a public transportation pass that did not cover the dentist's location, resulting in the missed appointment. Staff interviews confirmed there was no transportation policy and that the responsibility for arranging transportation was not fulfilled.
A resident with a documented beet allergy and intact cognition was repeatedly served beets on meal trays despite clear documentation of the allergy on meal tickets and face sheets. The resident reported sending the trays back and expressed concern for others with cognitive impairment. Staff interviews confirmed awareness of the issue, and review of facility policies and audits showed that procedures and training were in place, but the allergy was not consistently honored.
A resident with cognitive impairment was admitted with an electronically signed Admission Agreement after consent was obtained by phone, but the process did not include two proper witnesses as required. Facility staff were unsure of the identity of the person who gave consent, and the second staff member signed the document without witnessing the conversation, resulting in incomplete and potentially inaccurate medical record documentation.
A resident with a history of cerebral infarction and other medical conditions eloped from a facility after breaking her window twice. Despite exhibiting anxiety and hallucinations, the facility failed to implement effective interventions to prevent her elopement. The resident was eventually found in a coffee shop and transported to the hospital. The facility's lack of adequate supervision and safety measures led to this deficiency.
A resident with multiple medical conditions eloped from the facility by breaking a window. Despite staff efforts to locate her, she was not found until an hour later at a nearby coffee shop. The facility did not report the incident to the State Agency within the required 24-hour timeframe, as the Administrator believed it did not meet the criteria for reporting.
A long-term care facility failed to maintain an effective pest control program, leading to the presence of cockroaches and other insects in resident rooms, the kitchen, and common areas. Observations and interviews with residents and staff confirmed frequent sightings of pests, particularly in the kitchen. Despite regular treatments, the issue persisted, with the pest control company noting resistance from management to authorize comprehensive treatment. The facility lacked a formal pest control policy, relying instead on a contract with a pest control company.
The facility failed to properly label and date food items in the kitchen, as observed during an inspection. A torn bag with exposed food was found in the freezer without a label or date, and another bag was dated but not labeled. Interviews revealed that all kitchen staff were responsible for labeling and dating food, as per facility policy, but this was not consistently followed.
A facility failed to ensure a resident's dignity and privacy during incontinent care when a CNA left the door open and did not draw the privacy curtain, leaving the resident exposed. The resident, with multiple health conditions and dependent on staff for toileting, was visible from the hallway. Interviews with staff confirmed that the expected procedure to ensure privacy was not followed, resulting in a deficiency related to the resident's right to dignity and respect.
A medication cart on the 300 hall was found unlocked and unsupervised, with three compartments accessible. RN A, responsible for the cart, admitted to leaving it unattended while attending to a resident's needs elsewhere, failing to lock it properly. The unlocked drawers contained routine medications, respiratory treatments, and cleaning items, although narcotics were secured. Interviews confirmed that the facility's policy requires medication carts to be locked when not in use.
A facility failed to identify a resident as an elopement risk and complete a wandering/elopement assessment within 24 hours of admission, leading to the resident eloping and being found 1-2 miles away. The resident had a history of elopement and severe cognitive impairment, which was not adequately addressed. Interviews revealed communication gaps and procedural failures among staff.
The facility failed to ensure resident dignity and a clean environment. One resident was found with her pants down, exposing her private parts, while another had a full urinal causing a strong urine odor in his room. Additionally, a resident exhibited disruptive behaviors, including urinating in common areas and damaging property, which were not effectively managed by the staff.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for four residents, leading to rooms with a persistent urine odor. The memory care unit also had a pervasive urine odor and sticky floors, indicating inadequate cleaning practices. Staff interviews revealed inconsistencies in cleaning routines and responsibilities, and the facility lacked a specific policy on creating a homelike environment and managing urinals.
The facility failed to maintain an effective pest control program, leading to frequent sightings of insects such as crickets, cockroaches, and flies in various areas, including residents' rooms. Multiple residents and staff reported the presence of pests, and the facility's pest control measures were insufficient to address the ongoing issue effectively.
The facility failed to provide a communication aide for a resident diagnosed with hearing loss, compromising her right to a dignified existence and quality of life. Despite recommendations for follow-up with an ENT doctor, the resident lacked necessary communication tools, making it difficult to convey her needs. Interviews revealed a lack of awareness and concern from the DON and Administrator, and the facility lacked a specific policy to address communication needs.
The facility failed to protect a resident from verbal abuse by another resident during a supervised smoking session. Staff present did not intervene immediately, and interviews revealed a lack of awareness and consistent intervention. The affected resident, with a history of dementia and schizoaffective disorder, did not acknowledge the abuse and appeared unable to communicate effectively.
The facility failed to ensure residents who were unable to carry out activities of daily living received necessary grooming and personal hygiene services. An elderly female did not receive nail care, and another elderly female did not receive shaving care, despite their care plans indicating they required assistance. Staff inconsistencies and lack of documentation contributed to these deficiencies.
A facility failed to provide routine dental services for a resident with multiple medical conditions, including vascular dementia and dysphagia. The resident required dental extractions and dentures, but the facility did not obtain the necessary financial consent, leaving the resident without needed dental care. Lack of communication and follow-up among staff contributed to the deficiency.
Resident Left Unattended at Off-Site Appointment Due to Scheduling and Supervision Failures
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dementia, schizophrenia, osteoporosis, impaired balance, and a moderate level of cognitive impairment, was left unattended at an off-site medical appointment. The resident was transported by a facility van driver to a hospital for a scheduled appointment that had actually been canceled. The driver, after confirming details with an overnight nurse but receiving no special instructions, dropped the resident off at the hospital and left, without ensuring appropriate supervision or arrangements for the resident's return. The resident was found unsupervised outside in a hospital courtyard by a security guard, who then notified hospital staff and the facility. The resident's care plan indicated a need for supervision during ambulation with a walker due to physical mobility needs, but the resident was sent to the appointment without her required assistive device. The facility's appointment scheduling process failed when the scheduler did not update the appointment book or notify the van driver of the cancellation, despite being informed by the MDS coordinator and the resident's guardian that the appointment was no longer needed. As a result, the resident was left alone in an unfamiliar environment, with diminished cognition and altered physical ability, and without the necessary mobility support. Interviews with facility staff, including the DON and Administrator, confirmed that the facility's protocol required staff to accompany residents to off-site appointments when supervision was indicated, and that this protocol was not followed in this instance. The incident was documented in the facility's incident report, and the failure to provide adequate supervision and assistance devices as required by the resident's care plan led to the identification of an Immediate Jeopardy situation.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established plan or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in multiple rooms, including those of residents with severe cognitive impairments and chronic health conditions. Observations revealed live roaches in Resident #1's room, with 20 live roaches noted under the bed and on the floor. Resident #7 also reported issues with roaches in her room, and Resident #6 mentioned seeing bugs recently. Despite frequent spraying by a pest control company, the problem persisted, indicating the treatments were ineffective. Interviews with staff and residents highlighted a lack of awareness and communication regarding the pest issue. The Maintenance Director was unaware of the roach problem on hall 2200 until the day of the survey, and staff were supposed to document pest sightings in a log for the pest control technician to review. However, the log entries showed multiple sightings, suggesting a disconnect between reporting and action. CNA A and CNA B confirmed seeing roaches and believed pest control measures were in place, but the effectiveness was questioned. The facility's Director of Nursing acknowledged the ongoing pest issue, attributing it to the building's age and stating that efforts to eliminate pests had been made. The facility's sighting logs documented several pest sightings, and the pest control company had visited multiple times. Despite these efforts, the presence of pests continued, compromising the residents' right to a safe and clean environment as outlined in the facility's resident rights documentation.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. Observations revealed that the ice scoop storage receptacle was cracked and had pieces missing from the bottom, and the inside of the ice machine had visible brown and white substances on the upper inside of the door. The stovetop range's drip pans contained orange and brown dried food particles and substances, and the foil liners were soiled. Additionally, the facility was not using an ice scoop receptacle that was intact and clean, as required by professional standards. Further observations in the kitchen and dry storage area showed that several food items were not properly labeled or dated. For example, a bus tub of individually wrapped wheat bread slices lacked a preparation date, time, product name, or discard date. Multiple bags and packages of food, such as coconut flakes, cake mixes, noodles, pinto beans, and cornmeal, were either undated, unlabeled, or had unclear dating information. Some opened products, including Italian dressing, teriyaki marinade, and soy sauce, were not refrigerated as required by the manufacturer’s label. In the walk-in refrigerator, a steam table pan of meatballs was labeled incorrectly as salsa and did not have a discard date. Interviews with the Dietary Director and Administrator confirmed that their expectations were for all food items to be labeled and dated upon receipt and preparation, and for staff to be trained on these procedures. However, review of the daily kitchen cleaning schedule showed that the ice machine was not included, and in-service training records indicated that staff had received training on labeling, dating, storage, and sanitation. The facility’s food storage policy and the FDA Food Code require proper labeling, dating, and storage of food items, as well as regular cleaning and sanitation of equipment, which were not consistently followed in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective and ongoing pest control program, resulting in the presence of flies, gnats, and roaches in multiple areas throughout the building. Observations documented pests in resident rooms, the dining room, conference room, and near food service areas. Specific incidents included flies and gnats on and around a resident's bedside table, on bedsheets, and landing on the resident's skin, as well as roaches crawling on conference room walls and tables. Gnats were also observed near a resident's refrigerator that did not close properly, and flies were seen in the conference room and around food and beverage areas. Interviews with staff revealed a lack of a specific pest control policy, and staff acknowledged that the presence of pests could be related to cleanliness issues and was uncomfortable for residents. The administrator expressed surprise at the pest activity and was unable to comment on how residents felt about pests landing on them or their belongings. Resident council meeting minutes documented ongoing complaints about roach infestations over several months, with residents describing the situation as 'horrible.' Review of pest control invoices showed that while treatments were performed for cockroaches and flying insects, there were gaps in service documentation and continued evidence of pest activity. Emergency pest control services were provided in response to complaints, with recommendations for cleaning and removal of food sources, but pests remained present in the facility during the survey period.
Failure to Maintain Resident Dignity During Catheter Care and Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain resident dignity in two key areas: the use of privacy covers for urinary catheter bags and the simultaneous serving of meal trays to residents seated at the same table. Two residents with indwelling urinary catheters were observed without privacy covers on their catheter bags, both in their rooms and while ambulating in the hallway. Interviews with these residents revealed that the absence of privacy covers was distressing, with one resident expressing embarrassment and a desire for privacy. Staff interviews confirmed that facility policy and training required catheter bags to be covered at all times, yet the deficiency persisted, and there was no facility policy document specifically addressing catheter privacy covers. Additionally, surveyors observed that residents seated at the same dining table did not receive their meal trays at the same time. On multiple occasions, some residents were served and began eating while their tablemates waited for their trays, sometimes for several minutes. Observations included residents displaying signs of hunger and discomfort while waiting. Staff interviews confirmed that the facility's meal service policy required all residents at a table to be served before moving to the next table, and staff acknowledged that failing to do so could impact residents' sense of dignity and comfort. The report included detailed medical histories and care needs for the affected residents, many of whom had cognitive impairments, communication difficulties, or required assistance with eating. Despite these needs and established policies, the facility did not consistently implement practices to protect resident dignity during catheter care and meal service. Staff and administration interviews indicated awareness of the policies and the importance of these practices, but could not explain why the deficiencies occurred.
Failure to Obtain Resident Consent for Searches of Personal Belongings and Living Spaces
Penalty
Summary
Facility staff failed to honor residents' rights to be treated with respect and dignity, specifically by conducting searches of residents' wheelchairs, belongings, and rooms without obtaining resident consent. Multiple residents, all cognitively intact, reported that a social worker (SS) and other unidentified staff searched their personal possessions and living spaces for contraband, such as cigarettes and lighters, without permission. These actions were corroborated by resident interviews, staff interviews, and witness statements, as well as documentation in resident records. Residents described feeling embarrassed, harassed, angry, and singled out as a result of these searches, and some reported emotional distress and a decline in self-esteem. Specific incidents included a resident with a history of COPD, dementia, and muscle wasting, who was searched by the SS without consent while exiting and entering the facility. The SS took cigarettes from the resident's wheelchair without permission, leading to a confrontation and emotional upset. Another resident, with a history of stroke and muscle atrophy, reported that the SS searched her wheelchair for marijuana without asking for consent, and took her cigarette case. A third resident, with diagnoses including dementia and bipolar disorder, also reported being searched by the SS without consent. These residents stated that the searches made them feel unwanted and disrespected, and some altered their behavior out of fear of further searches. During a resident council meeting, nine additional residents confirmed that their rooms and belongings had been searched by staff without their consent, and some reported that personal items were taken and given to other residents. Staff interviews revealed inconsistent understanding and application of facility policy regarding searches, with some staff stating they always asked for consent, while others admitted to searching when contraband was suspected. The facility's written policy explicitly prohibits searching a resident's body or possessions without consent, yet the administrator and other staff acknowledged that searches were conducted without consent, particularly when illegal substances were suspected.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents whose rooms were observed to be unclean, cluttered, and unsanitary. Observations revealed that one resident's room had a persistent fly problem, while another resident's room was cluttered with dirty clothes, food containers, and trash, despite repeated requests for assistance with cleaning and organizing. Staff interviews confirmed that requests for cleaning help were not addressed in a timely manner, and the resident expressed distress over the situation, stating it made her feel claustrophobic and wanting to leave the facility. Another resident was found in a room with dirty and stained bed linens, lacking a blanket and pillowcase, and the room had a noticeable odor of cigarette smoke. The resident expressed a desire for clean bedding but did not receive it. Additionally, a fourth resident reported that housekeeping did not clean her room unless specifically asked, and that linens provided were often stained and had holes. The resident also noted a loose baseboard in the bathroom, which she stated allowed roaches to enter, and expressed fear of walking on the dirty floor due to a recent toe amputation and surgical wound. Facility policy required daily cleaning of resident rooms and timely response to requests for assistance, but interviews with staff, including the DON and ADM, revealed that these expectations were not met. Staff acknowledged that cluttered and unclean rooms were not homelike and that residents should receive cleaning assistance promptly, yet the observed conditions and resident reports indicated that these standards were not upheld.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the management of their medical, dental, and psychosocial needs. For one resident with multiple complex diagnoses, including cerebrovascular disease, schizoaffective disorder, and vascular dementia, the care plan did not address her physician-ordered oxygen therapy. Despite clinical orders for oxygen use and observations confirming the resident's use of oxygen, there was no documentation in the care plan regarding oxygen administration or care, nor instructions for changing or cleaning oxygen equipment. Another resident with diagnoses such as bladder cancer, diabetes, and muscle wasting had a documented food allergy to beets and had requested a dental exam upon admission. The care plan did not include information about his food allergy or dental needs, and there was no record of a dental exam being completed. The resident reported receiving meals containing beets despite his allergy and missing a dental appointment for dentures, which he had scheduled himself and communicated to staff. A third resident with a diagnosis of PTSD did not have her mental health needs addressed in her care plan. The resident reported that no staff had inquired about her PTSD, triggers, or necessary interventions, despite her preference for female staff and English-speaking caregivers due to past trauma. Interviews with staff revealed uncertainty about responsibility for updating care plans to address PTSD and related accommodations, and the care plan lacked any documentation of her diagnosis or required interventions.
Failure to Provide Regular Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene. Four residents were identified as not receiving regular showers as scheduled, despite their care plans and shower schedules indicating the need for assistance with bathing. Documentation in shower logs frequently marked residents as 'not available,' 'refused,' or 'not applicable,' but interviews with residents revealed discrepancies, with some residents stating they did not refuse showers and were available on their scheduled days. Residents affected included individuals with significant medical and cognitive conditions, such as schizophrenia, anemia, hemiplegia, diabetes, and morbid obesity. These residents required varying levels of assistance with personal hygiene, as documented in their Minimum Data Set (MDS) assessments and care plans. Observations noted poor hygiene, such as oily and dirty hair, and residents expressed dissatisfaction with the lack of regular showers, with some reporting feelings of uncleanliness and discomfort. In some cases, residents proactively reported the issue to facility leadership, and grievances were filed regarding missed showers. Interviews with staff, including CNAs, RNs, the DON, and the ADON, revealed inconsistent understanding and documentation practices regarding shower provision and refusal. Staff provided varying explanations for the use of 'not applicable' in shower logs, including residents being out of the facility, room changes, or staff running out of time. There was also a lack of clarity on follow-up procedures when showers were missed or refused. Facility policy required that residents unable to perform ADLs receive necessary care to maintain hygiene, but this was not consistently implemented, resulting in missed showers for multiple residents.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessments, care plans, and preferences of three residents, resulting in a lack of both group and individual activities designed to meet their physical, mental, and psychosocial needs. Observations revealed that these residents, who had varying degrees of cognitive impairment, physical limitations, and health conditions such as intellectual disabilities, dementia, and terminal illness, were frequently left without any form of stimulation or engagement in their rooms. Despite care plans specifying the need for sensory stimulation, 1:1 in-room activities, and honoring resident preferences, these interventions were not consistently implemented. For one resident with severe cognitive impairment and a history of enjoying music and sports, multiple observations showed him awake in his room without any stimulation, contrary to his care plan which called for regular sensory and 1:1 activities. Another resident, who preferred to stay in his room and had mild cognitive impairment, was also observed repeatedly without any activities or stimulation, despite a care plan that required staff to encourage participation and provide individual activities several times a week. A third resident, on hospice care and with significant memory issues, was similarly found asleep or awake in his room with no evidence of activities being offered, despite interventions calling for 1:1 in-room engagement. Interviews with facility staff, including the newly appointed activity director, DON, and administrator, confirmed that there was a lack of consistent activity provision and documentation for these residents. The activity director acknowledged being new to the role and still familiarizing himself with residents' needs, while the DON and administrator expressed expectations that bedbound residents should receive in-room activities as per policy. However, documentation and direct observations indicated that these expectations were not being met, and the facility's own policy requiring regular in-room visits for such residents was not followed.
Failure to Maintain Infection Control and Hand Hygiene Practices
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during meal tray distribution and personal care activities for multiple residents. One CNA did not wash or sanitize hands between handling meal trays for three different residents, despite being trained on infection control procedures. Both the CNA and a nurse confirmed that the policy required hand sanitizing between each tray, and the CNA admitted to forgetting to perform hand hygiene. The nurse and administrator also acknowledged the expectation for hand hygiene and monitoring by nursing staff, but could not explain the lapse. During peri care for a resident with multiple diagnoses including diabetes, dementia, and chronic obstructive pulmonary disease, a CNA did not perform hand hygiene before or after care, nor when changing gloves. The CNA also reused disposable wipes by folding them, contrary to policy. The CNA and ADON both stated that hand hygiene should be performed before and after resident contact and when changing gloves, and that wipes should not be reused. The resident's care plan required cleansing the peri-area with each incontinent episode to prevent infection and skin breakdown. Another resident with an indwelling urinary catheter reported that no one had cleaned his catheter since admission, and that the cleaning performed was painful. The DON stated there was no specific policy for catheter care, while the administrator expected daily cleaning. The resident's care plan included monitoring for signs of infection and trauma related to the catheter. Facility policies reviewed required hand hygiene and proper glove use during peri care, and the hand washing policy emphasized infection prevention for all staff.
Failure to Provide Required Square Footage in Shared Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in five shared resident rooms, specifically rooms 201, 404, 504, 2405, and 2505. Observations revealed that each of these rooms contained three beds, with the beds arranged in a row, and the middle bed (Bed B) in each room having significantly less living space than the others. Digital measurements confirmed that several beds, particularly the middle beds in these rooms, had less than the required 80 square feet of space, with some as low as 48.84 square feet. The facility's Bed Classification form certified these rooms for three residents each, but actual measurements did not meet regulatory requirements for all beds. Interviews with the Administrator (ADM) and Director of Nursing (DON) indicated a lack of awareness regarding the specific square footage requirements and the absence of any waivers or variances for these rooms. The ADM stated that he relied on the Bed Classification form and was unaware that some beds did not meet the minimum space requirement. The DON also confirmed she was not aware of the requirements until informed by surveyors and acknowledged that insufficient space could impact residents' ability to move and receive care. No residents were reported to have complained about the space at the time of the survey.
Failure to Ensure Privacy During Incontinent Care
Penalty
Summary
A deficiency was identified when a staff member failed to provide full personal privacy for a male resident during incontinent care. The resident, who had a history of dementia, psychotic and mood disturbances, hemiplegia, traumatic brain injury, schizophrenia, major depressive disorder, and aphasia, was observed receiving pericare with the privacy curtain only partially closed between beds and the front curtain left open. The resident's roommate was present in the room, watching television at a high volume. During the care, the resident attempted to close the curtain further himself to increase his privacy. Interviews confirmed that the resident felt uncomfortable and lacked privacy during the care, and the CNA involved acknowledged that the curtain should have been fully closed. The DON also stated that staff are expected to close both the door and privacy curtains during such care. Review of facility in-service records and policy indicated that staff had been instructed to ensure privacy by closing curtains and doors during personal care, but this procedure was not followed during the observed incident.
Unauthorized Use of Physical Restraints Without Medical Need or Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. Specifically, a cognitively intact female resident with a history of dementia, bipolar disorder, major depressive disorder, cognitive communication deficit, and muscle wasting was found with two triangular wedges on her bed that prevented her from getting off the bed. The resident's care plan and medical orders did not include the use of wedges, and there was no documentation of a medical need or physician order for their use. Observations confirmed that the resident did not have a pressure ulcer, which is the stated reason for wedge use according to facility staff. Interviews with staff, including an LVN, CNA, DON, and the administrator, revealed that the facility identifies itself as a no-restraint facility and that wedges are only to be used for positioning residents with pressure ulcers and require a physician's order. Staff were unable to provide a reason for the use of wedges in this case, and there was no communication or documentation supporting their use for this resident. The facility's restraint policy requires a specific medical symptom and physician order before restraints are used, which was not followed in this instance.
Failure to Address PTSD in Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that addressed a resident's diagnosis of PTSD. The resident, an adult female with a history of PTSD related to past abuse by males, was admitted with this diagnosis clearly documented in her records. Despite this, the baseline care plan did not include any instructions or interventions to address her PTSD. Interviews revealed that the resident was not asked about her PTSD, triggers, or preferred interventions, and she expressed a preference for female care staff and for being spoken to in English, as these factors affected her comfort and mental health. Staff interviews indicated uncertainty regarding responsibility for updating care plans to address PTSD and its accommodations. The social worker was unsure if PTSD should be included in the care plan and had not inquired about the resident's needs related to this diagnosis. Other staff members, including the social services staff and DON, acknowledged that care plans should be updated to reflect mental health diagnoses and related interventions, but this was not done for the resident in question. The facility's policy on baseline care plans was requested but not provided before the survey exit.
Unlabeled Soap in Resident Room Leads to Accidental Ingestion
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free from accident hazards, resulting in a resident being given a sip of shower gel that was left in an unlabeled cup in the resident's room. The incident involved an 80-year-old male with vascular dementia, dysphagia, and cognitive communication deficits, who was on a mechanical soft diet with nectar thick liquids. The resident's family member (FM) found a cup of red liquid next to the TV in the resident's room and, mistaking it for a consumable item, gave it to the resident. The resident immediately spit out the liquid and began coughing. Nursing progress notes and interviews confirmed that the cup containing the soap was not labeled and was left in an accessible area of the resident's room. The FM believed the liquid was Jello due to its consistency, which was similar to the thickened liquids prescribed for the resident. Staff, including an LVN and the DON, were unable to determine how the soap ended up in the cup or who placed it there. The LVN assessed the resident after the incident and found no immediate adverse effects, and the resident was monitored as per protocol. The facility's policy required that the environment be kept as free from accident hazards as possible and that all incidents be reported and investigated. However, the presence of an unlabeled cup containing soap in the resident's room constituted a failure to secure potentially hazardous substances, directly leading to the incident. The investigation did not reveal the source of the soap or how it was left in the resident's room, and staff interviews indicated a lack of awareness regarding the potential harm of ingesting soap.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD. The resident's comprehensive and baseline care plans did not document the PTSD diagnosis or include any interventions to address or mitigate the resident's trauma-related needs. Despite the resident's intact cognition and clear communication of her preferences and triggers, such as a preference for female care staff and English-speaking staff due to past abuse by males and discomfort with other languages, these needs were not assessed or incorporated into her care plan. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assessment and care planning for residents with PTSD. The social worker (SW) admitted to not asking about PTSD-related accommodations and was unsure about the process for updating care plans for such diagnoses. The staff scheduler (SS) and DON both acknowledged that care plans should be individualized for residents with PTSD, including identification of triggers and appropriate interventions, but these steps were not taken for the resident in question. The facility's own policy requires that care plans be person-centered, trauma-informed, and culturally competent, incorporating residents' diagnoses, preferences, and triggers. However, the policy was not followed in this case, as the resident's PTSD and associated care needs were omitted from her care plan, and staff were not aware of or addressing her specific triggers. The absence of this information in the care plan meant that staff were not equipped to provide appropriate care for the resident's mental health needs.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated rate of 7.69% based on 2 errors out of 26 observed opportunities. One incident involved a medication aide (MA R) administering a whole Fish Oil 1000 MG gel capsule to a resident who had physician orders for all medications to be crushed. MA R did not crush the gel capsule, stating that it could not be crushed and that the resident typically takes it whole. MA R was unaware of the facility's policy regarding gel capsules with crush orders and relied on personal experience rather than established protocols. Another incident involved a medication aide (MA T) administering Metoprolol Succinate ER to a resident despite the resident's blood pressure and heart rate being outside the parameters specified in the physician's order, which required the medication to be held under such conditions. Both medication aides demonstrated a lack of adherence to the facility's medication administration policy, which requires medications to be administered as ordered and in accordance with manufacturer specifications, including holding medications when vital signs are outside prescribed parameters and crushing medications as ordered.
Significant Medication Error Due to Failure to Follow Blood Pressure Parameters
Penalty
Summary
A medication administration error occurred when a staff member administered Metoprolol Succinate ER to a male resident diagnosed with essential hypertension, despite the resident's vital signs being outside the prescribed parameters. The physician's order specified that the medication should be held if the systolic blood pressure was less than 110 or the heart rate was less than 60. On the observed date, the resident's blood pressure was 145/67 and heart rate was 54, yet the medication was still given. The resident was noted to be severely cognitively impaired, with a BIMS score of 6, and required staff to follow medication administration protocols closely. The staff member acknowledged in an interview that the medication should not have been administered under these circumstances and that staff are regularly in-serviced on proper medication administration procedures. Facility policy also requires staff to obtain and record vital signs and to hold medications when vital signs fall outside of physician-ordered parameters.
Unsecured Medication Carts and Improper Medication Storage
Penalty
Summary
Surveyors observed that drugs and biologicals were not consistently stored in locked compartments as required by state and federal regulations. Specifically, two out of four medication carts reviewed were found unlocked: one on the 2400 hall and another by the front entrance on the lower level. During a medication pass, a medication aide (MA T) left the medication cart unlocked and unattended while seeking clarification from the charge nurse, leaving medications out of her sight and in the presence of the surveyor. Later that day, another medication cart was found unlocked and unattended near the front entrance, with no staff nearby and residents present in the area. Interviews with MA T revealed an awareness of the facility's policy requiring medication carts to be locked when unattended, but she admitted to leaving the cart unlocked because the surveyor was present, despite knowing the rules. The Director of Nursing (DON) confirmed that staff are expected to lock carts when not in use to prevent unauthorized access. Review of facility records showed that staff had been in-serviced on medication storage, but the written medication administration policy did not address medication storage or locking carts.
Failure to Provide Timely Transportation for Diagnostic Services
Penalty
Summary
A deficiency occurred when the facility failed to provide timely transportation for a resident to a scheduled MRI imaging appointment, resulting in the appointment being canceled due to late arrival. The resident, who has a history of schizophrenia, epilepsy, chronic right hip pain, and a pelvis fracture, expressed frustration over the missed appointment and ongoing pelvic pain. The resident was not informed about the rescheduling of the appointment or who would be responsible for future transportation, especially after being told that the facility van driver would no longer be working there. No communication was provided to the resident regarding future appointments. Interviews with staff revealed that the process for arranging transportation involved scheduling appointments in a central book, but a breakdown occurred when the facility van was unavailable and the driver was unaware that an alternative vehicle had been secured. This miscommunication led to the resident being transported late. The staff responsible for transportation coordination were unsure if the resident or the medical provider had been notified about the missed appointment. Additionally, the facility administrator confirmed that there was no transportation policy in place at the time of the incident.
Failure to Arrange Transportation for Dental Appointment
Penalty
Summary
The facility failed to assist a resident in arranging transportation to and from a dental services location, resulting in the resident missing a dental appointment for denture castings. The resident, who had diagnoses including bladder cancer, muscle wasting, malaise, and vitamin D deficiency, had requested a dental exam upon admission, but there was no record of a dental exam in his medical record. The resident made his own dental appointment and informed the facility's CST, who was responsible for scheduling transportation. However, the facility van was unavailable due to repairs, and the CST provided a public transportation pass without confirming that the public transit covered the dentist's location. As a result, the resident was unable to reach the appointment and missed it. Interviews with the CST and ADM confirmed that the facility did not have a transportation policy and that it was the responsibility of the interdisciplinary team to ensure residents were transported to appointments. The CST acknowledged not verifying the public transportation coverage area and stated it was their responsibility to secure transportation. The ADM also stated that residents should be transported as scheduled and that missing appointments could negatively affect residents. The resident expressed concern about missing necessary dental care and uncertainty about future transportation arrangements.
Failure to Accommodate Documented Food Allergy
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's documented allergy. The resident, a male with diagnoses including anemia, type 2 diabetes with a foot ulcer, and vitamin D deficiency, had a known allergy to beets, which was clearly listed on his face sheet and meal ticket. Despite this documentation, the resident was served beets on his meal tray, as confirmed by both his statements and review of meal tickets. The resident, who was cognitively intact, reported that he repeatedly received trays containing beets and had to send them back, expressing concern for other residents who might not be able to recognize or report such errors due to cognitive impairment. Observations of meal service showed that staff performed hand hygiene and checked trays, but no discrepancies were noted during the observed meal. However, interviews with dietary and nursing staff confirmed awareness of the resident's allergy and acknowledged that the resident had received beets on his tray at times. The facility's process involved multiple checkpoints by different staff members, including the cook, diet aide, nurse, and CNA, to verify tray accuracy, yet the error still occurred. Review of facility policies indicated that tray line audits and allergy awareness procedures were in place, and in-service trainings on food allergies had been conducted. Despite these measures, the resident's allergy was not consistently honored, as evidenced by the repeated serving of beets. The care plan for the resident did not document the food allergy, and tray line audits did not identify any concerns or trends related to this issue.
Failure to Properly Witness and Document Admission Agreement
Penalty
Summary
The facility failed to ensure that a resident's medical records, specifically the Admission Agreement, were accurately documented and properly witnessed according to policy. The Admission Agreement for an 80-year-old male resident with multiple diagnoses, including vascular dementia and impaired decision-making ability, was signed electronically after consent was received during a phone conversation. However, the process did not include two witnesses to the consent, as required. The staff member responsible for obtaining consent was unsure whether she spoke with the correct family member and entered the name based on information from the hospital face sheet, without confirming the power of attorney status at the time. Further review revealed that the electronic system required two facility representatives to sign the document, but the second signatory did not actually witness the phone conversation. Both the Admissions Coordinator and the Assistant Business Office Manager confirmed in interviews that the second signature was added after reviewing the form, not after witnessing the consent. The Assistant Business Office Manager stated he was unaware of who was spoken to and did not witness the conversation, despite signing as a witness. The facility's policy requires that documentation in the medical record be accurate, complete, and timely, reflecting the actual experiences of the resident. In this case, the Admission Agreement was not properly witnessed, and there was uncertainty about the identity of the person who provided consent. This resulted in incomplete and potentially inaccurate documentation in the resident's medical record.
Resident Elopement Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, leading to a resident's elopement. The resident, who had a history of cerebral infarction, hypertension, aphasia, and other medical conditions, broke her window and attempted to leave the facility. Despite this initial attempt, the facility did not implement effective interventions to prevent further incidents. On a subsequent occasion, the resident successfully eloped from the facility after breaking her window again. The staff's response included attempts to follow the resident and notify the police, but they were initially unable to locate her. The resident was eventually found in a coffee shop, where she was agitated and refused assistance, leading to her being transported to the hospital. The facility's records and interviews revealed that the resident had exhibited signs of anxiety, hallucinations, and restlessness prior to the incidents. Despite these behaviors, there were no documented reevaluations of her wandering risk, and the care plan did not adequately address her needs for supervision and safety. The facility's failure to address these issues resulted in a deficiency that placed the resident at risk for harm.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident within the required 24-hour timeframe. The resident, who had a history of cerebral infarction, hypertension, aphasia, and other medical conditions, broke a window and left the facility. Despite staff efforts to locate her, she was not found until an hour later at a nearby coffee shop. The facility did not report this incident to the State Agency (SA) as required by regulations. The resident's care plan indicated she had behavior problems and required monitoring for adverse reactions to anti-anxiety medications. On the night of the incident, staff observed the resident breaking a window and leaving the facility. Although staff followed her and eventually found her, the facility's administration did not consider the incident reportable, as they believed the resident was within eyesight at all times and did not meet the definition of elopement. Interviews with staff revealed confusion about the reporting requirements and the definition of elopement. The Administrator believed the incident did not meet the criteria for reporting, while other staff members considered it an elopement. The facility's policies required reporting such incidents, but the Administrator did not report it, believing the staff's response was appropriate. This failure to report could place residents at risk of harm.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests, including cockroaches and other insects, in various areas such as resident rooms, the kitchen, dining room, and shower room. Observations on 08/06/2024 revealed multiple instances of insects, including crickets and small bugs, in these areas. Interviews with residents and staff confirmed frequent sightings of cockroaches, particularly in resident rooms and the kitchen, indicating an ongoing issue with pest control. Interviews with staff members, including the Dietary Aide (DA), Assistant Food Service Supervisor (AFSS), and cooks, revealed that cockroaches were a known problem throughout the facility. The Maintenance Director (MD) and Food Service Supervisor (FSS) acknowledged the issue, with the MD noting that a full treatment had not been conducted in over a year and a half. The pest control company confirmed the presence of a significant infestation in the kitchen and indicated that the facility's management had been resistant to authorizing a comprehensive treatment. The facility's pest control logs and service reports documented numerous sightings and treatments for cockroaches and other pests over several months. Despite regular monthly treatments and additional services as needed, the pest problem persisted, with sightings recorded in various locations, including resident rooms, the kitchen, and common areas. The facility's administration acknowledged the ongoing challenge and the need for a more extensive pest control approach, but no formal pest control policy was in place, only a contract with a pest control company.
Deficiency in Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in the kitchen. During an inspection, a torn bag with exposed food was found in the freezer without any label or date. Another bag of food was observed with a date but no label indicating its contents. The Food Service Supervisor (FSS) instructed staff to re-bag and date the exposed food, indicating a lack of initial compliance with labeling protocols. Interviews with the FSS and other staff members revealed that all kitchen staff were responsible for labeling and dating food items, including the date of receipt or expiration. The facility's policy required all food to be labeled, dated, and covered, as confirmed by a review of the policy and the Dietary Manager Daily Checklist. Despite these guidelines, the deficiency in labeling and dating was evident, as acknowledged by the staff and administration during interviews.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, a Certified Nursing Assistant (CNA) did not provide privacy to a resident during incontinent care by leaving the door open and not drawing the privacy curtain, which left the resident exposed and visible from the hallway. This incident involved a female resident with multiple diagnoses, including conversion disorder with seizures, cerebral palsy, peripheral vascular disease, muscle wasting, repeated falls, depression, and moderate intellectual disabilities. The resident was dependent on staff for toileting and was always incontinent of bowel and bladder. During the investigation, interviews with staff, including the CNA involved, revealed that the expected procedure for providing privacy during incontinent care was not followed. The CNA admitted to not closing the door or drawing the curtain, acknowledging that this could lead to the resident being seen by others, which is a dignity issue. Other staff members, including another CNA and the Director of Nursing (DON), confirmed that the standard practice was to ensure privacy by closing the door or curtain. The facility's policy on perineal care also emphasized the importance of providing privacy. The failure to adhere to these procedures resulted in a deficiency related to the resident's right to dignity and respect.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were stored in locked compartments with access restricted to authorized personnel only. During an observation, a medication cart on the 300 hall was found unlocked and unsupervised, with three compartments accessible. RN A, who was responsible for the cart, admitted to leaving it unattended while attending to a resident's needs elsewhere. She acknowledged that she should have locked the cart and taken the keys with her but believed she might not have pressed the lock hard enough. The unlocked drawers contained routine medications, respiratory treatments, and cleaning items, although narcotics were secured in a separate locked drawer. Interviews with staff, including MA D and the DON, confirmed that the facility's policy requires medication carts to be locked when not in use. The DON and RCN both expressed that leaving carts unlocked could lead to unauthorized access to medications. The facility's policy, last revised in 2019, clearly states that medication carts must be locked at all times when not in use and should not be left unattended in resident care areas.
Failure to Identify and Manage Elopement Risk
Penalty
Summary
The facility failed to identify a resident as an elopement risk from his admission paperwork or complete a wandering/elopement assessment within 24 hours of admission. This resulted in the resident eloping from the facility for approximately three hours and being located 1-2 miles away at a busy intersection. The resident had a history of elopement and severe cognitive impairment, which was not adequately addressed upon his admission to the facility. The resident's care plan was only revised to include elopement risk interventions after the incident occurred. The Director of Nursing (DON) admitted that the wandering/elopement assessment had not been completed prior to the elopement and that it was the responsibility of the social worker, who was subsequently suspended and then voluntarily quit. The DON also acknowledged that the resident was known to be at risk of elopement but was placed on the second floor instead of the memory care unit, which was deemed too restrictive. The failure to complete the assessment in the required timeframe directly led to the resident's elopement. Interviews with various staff members revealed a lack of communication and proper procedures in place to prevent such incidents. The receptionist, social workers, and nurses all provided accounts of the events leading up to and following the elopement, highlighting gaps in the facility's processes. The facility's investigation confirmed that no specific individual was at fault, but the overall lack of diligence in assessing the resident's elopement risk and implementing appropriate interventions was evident.
Failure to Ensure Resident Dignity and Clean Environment
Penalty
Summary
The facility failed to ensure that Resident #20 was treated with respect and dignity. During an observation, Resident #20 was found sitting on her walker with her pants down, exposing her private parts. The resident's call light was on the ground and away from her bed, making it difficult for her to call for assistance. Interviews with CNAs revealed that they were unaware of the incident and did not recognize the potential negative impact on other residents. The resident's care plan indicated she required extensive assistance with dressing due to her cognitive impairments and physical debility, but this assistance was not provided in a timely manner. Resident #395 experienced neglect in the form of inadequate toileting assistance. His urinal was found full and on the ground next to his bed, causing a strong urine odor in his room. Despite the facility's policy that urinals should be emptied and cleaned every two hours, staff interviews indicated that this was not consistently done. The resident reported that his urinal had been full for three hours and that he had requested a new urinal but did not receive one. Housekeeping staff confirmed that they had received complaints about the cleanliness of residents' rooms and the smell of urine. Resident #65 exhibited disruptive and unsanitary behaviors, including urinating in common areas and damaging facility property. Despite being care planned for these behaviors, the facility failed to manage them effectively. Interviews with staff and other residents revealed that Resident #65's actions created an uncomfortable and unsanitary environment. The resident's behaviors, such as urinating in the elevator and dining room, were well-known to the staff, including the Administrator and DON, but were not adequately addressed. This failure to manage the resident's behaviors compromised the safety and comfort of other residents in the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for four residents, leading to rooms with a persistent urine odor. Resident #41's room smelled of urine, and her call light was found behind her bed, making it inaccessible. Resident #129's room also had a urine odor, and he was found sleeping with a bed sheet covering his body and face. Resident #395's room had a full urinal on the ground, which had been there for three hours, causing a strong urine odor that bothered him. Resident #141's room also smelled of urine, and she reported that staff did not clean her room as requested. The memory care unit had a pervasive urine odor and sticky floors, indicating inadequate cleaning practices. Staff interviews revealed inconsistencies in cleaning routines and responsibilities. CNA I stated that residents' rooms were cleaned every 20 minutes, while housekeeping staff were responsible for cleaning rooms three times a day. However, multiple staff members, including CNA E and HK Q, acknowledged that the urine odor was a persistent issue and that residents could be negatively affected by it. Despite these claims, there was no evidence of a consistent and effective cleaning protocol to address the urine odor. The facility's policies on housekeeping and resident rights emphasized the importance of maintaining a clean and safe environment. However, observations and interviews indicated that these policies were not effectively implemented. The facility lacked a specific policy on creating a homelike environment and managing urinals, contributing to the ongoing issue of urine odor in residents' rooms and the memory care unit. This deficiency placed residents at risk of discomfort and diminished quality of life, as evidenced by the persistent urine odor and residents' complaints about inadequate cleaning.
Inadequate Pest Control Program
Penalty
Summary
The facility failed to maintain an effective ongoing pest control program, which placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Observations and interviews revealed the presence of insects such as crickets, cockroaches, and flies in various areas of the facility, including residents' rooms, the nursing station, and the dining area. Multiple residents and staff members reported frequent sightings of insects, and some residents expressed concerns about the cleanliness of their rooms and the presence of pests. Despite these reports, the facility's pest control measures were insufficient to address the ongoing issue effectively. Resident #4, a male with severe cognitive impairment, was observed to have crickets in his room on multiple occasions. Resident #141, a female with severe cognitive impairment, reported that insects were always present in residents' rooms and expressed dissatisfaction with the cleaning efforts. Additionally, Resident #13, a male with moderate cognitive impairment, was observed with a fly on his shirt, and Resident #184, a female who was cognitively intact, reported seeing cockroaches in residents' restrooms. These observations and interviews indicate that the facility's pest control program was not adequately addressing the pest problem, leading to a compromised living environment for the residents. Interviews with staff members, including CNAs, housekeeping staff, and the Maintenance Director, revealed inconsistencies in the frequency and effectiveness of pest control treatments. While some staff members stated that pest control visited the facility once a month, others mentioned more frequent visits. However, the presence of pests persisted, and staff members acknowledged that residents could be negatively affected by insects in their rooms. The facility's pest control logs and service reports indicated that treatments were conducted, but the ongoing sightings of pests suggest that these measures were not sufficient to eliminate the problem. The lack of a policy and procedure on maintaining a homelike environment further contributed to the deficiency in pest control management.
Failure to Provide Communication Aide for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide a communication aide for a resident diagnosed with hearing loss, which compromised the resident's right to a dignified existence, self-determination, and quality of life. The resident, who has a history of cerebral infarction, vascular dementia, and other mental health conditions, was found to have profound hearing loss and was recommended for follow-up with an ENT doctor. Despite this, the facility did not provide necessary communication tools such as a whiteboard or writing implements, making it difficult for the resident to communicate her needs effectively. During an observation, the surveyor noted the absence of any communication devices in the resident's room. The resident confirmed that she had been communicating with staff by writing everything down but faced difficulties when she did not have paper or a pencil. This lack of communication tools hindered her ability to convey her needs to the staff, affecting her overall quality of life. Interviews with the DON and the Administrator revealed a lack of awareness and concern regarding the resident's communication needs. The DON acknowledged the importance of communication aids, while the Administrator initially dismissed the issue as psychological rather than medical. The facility also lacked a specific policy to address resident communication needs, further contributing to the deficiency.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident. During a supervised smoking session, one resident verbally abused another by yelling and making demeaning comments. Two staff members were present but did not intervene immediately. The affected resident, who has a history of dementia and schizoaffective disorder, did not acknowledge the abuse and appeared unable to communicate effectively, using hand gestures instead of verbal requests. Interviews with staff revealed a lack of awareness and intervention regarding the verbal abuse. One staff member claimed not to recall the incident, while another admitted to being preoccupied with handing out cigarettes. The Activity Aide/Smoke Aide acknowledged that some residents were mean to the affected resident and tried to redirect them, but the abuse persisted. The resident's guardian also reported instances of bullying and verbal abuse during visits, which were communicated to the facility's social worker. The facility's policies on promoting resident dignity and preventing abuse were not effectively implemented. Staff interviews indicated a lack of consistent intervention and awareness of the resident's emotional state. The Director of Nursing and the Administrator both acknowledged the verbal abuse but did not initially recognize it as such. The facility's failure to protect the resident from verbal abuse and to ensure a safe and respectful environment was evident in the observations and interviews conducted during the survey.
Failure to Provide Necessary Grooming and Personal Hygiene Services
Penalty
Summary
The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #102 did not receive nail care, and Resident #182 did not receive shaving care. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors. Resident #102, an elderly female with diagnoses including schizophrenia, unspecified dementia, and major depressive disorder, was observed with long fingernails. Despite her care plan indicating she required assistance with personal hygiene, there was no documented history of her refusing nail care. Interviews with staff revealed inconsistencies in the provision of nail care, with some staff unaware of the schedule or failing to offer nail trims due to shift changes or personal emergencies. Resident #182, an elderly female with severe cognitive impairment and a history of CVA, was observed with long whiskers on her chin. She expressed a preference for shaving, but staff had not offered this service. Interviews indicated that shaving was supposed to be offered on shower days and Sundays, but there was no consistent documentation or follow-up on refusals. Staff were also unsure about the last time she received a shave, and there was no in-service training on grooming, showers, nail care, or shaving care documented for the year.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for a resident with multiple medical conditions, including vascular dementia, iron deficiency anemia, and dysphagia. The resident, who had no natural teeth and was on a mechanically altered diet, required dental extractions and dentures as recommended by a dentist. However, the facility did not obtain the necessary financial consent or declination for the recommended dental services, leaving the resident without the needed dental care. The deficiency was identified through a series of interviews and record reviews. The social workers (SW A and SW B) were responsible for obtaining consents for treatment, but there was a lack of communication and follow-up between them. SW A was initially responsible for obtaining the consent but did not complete the process. SW B, who took over the responsibility after returning from maternity leave, also did not follow up adequately. The dental provider had sent multiple requests for a signed payment letter, but no action was taken by the facility staff. The Director of Nursing (DON) and the Administrator were not fully aware of the resident's dental needs and the financial requirements for the dental services. The resident expressed a desire for dentures despite the cost, but the facility did not take the necessary steps to facilitate the process. The lack of coordination and communication among the facility staff led to the resident not receiving the required dental care, which could impact her ability to chew and enjoy her food.
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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